Healthcare Provider Details

I. General information

NPI: 1912599465
Provider Name (Legal Business Name): SUNGHYUN KIM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2021
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 MIDDLEFIELD RD # 1
MENLO PARK CA
94025-4001
US

IV. Provider business mailing address

60 VINTAGE CIR UNIT 156
PLEASANTON CA
94566-6538
US

V. Phone/Fax

Practice location:
  • Phone: 650-249-9803
  • Fax:
Mailing address:
  • Phone: 216-218-1943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number112817
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number062981-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: