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General NPI Number Information
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NPI Number | 1053625715
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Entity Type | Individual
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Provider Name | KELLY YEON SU KIM D.D.S
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Gender | Female
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Dates
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Enumeration Date | 08/04/2010
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Last Update Date | 06/16/2011
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Provider Practice Location Address
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Address Line | 30001 CROWN VALLEY PKWY SUITE G
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City | LAGUNA NIGUEL
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State | CA
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Zip | 92677-1723
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Country | US
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Telephone | 949-495-4245
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Fax |
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Provider Business Mailing Address
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Address Line | 30001 CROWN VALLEY PKWY SUITE G
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City | LAGUNA NIGUEL
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State | CA
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Zip | 92677-1723
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Country | US
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Telephone | 949-495-4245
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 58075
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 055114
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License Number State | NY
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