Healthcare Provider Details

I. General information

NPI: 1245578483
Provider Name (Legal Business Name): DR. HYONG JOON KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30195 FRASER DR
LAKE ELSINORE CA
92530-7006
US

IV. Provider business mailing address

1000 VALE TERRACE DR
VISTA CA
92084-5218
US

V. Phone/Fax

Practice location:
  • Phone: 951-252-2720
  • Fax: 760-414-3892
Mailing address:
  • Phone: 844-308-5003
  • Fax: 760-414-3892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number62103
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: