Provider Demographics
NPI:1023169042
Name:KIM, SANDY H (DDS)
Entity type:Individual
Prefix:DR
First Name:SANDY
Middle Name:H
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25567 HURON ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3722
Mailing Address - Country:US
Mailing Address - Phone:909-799-6636
Mailing Address - Fax:
Practice Address - Street 1:51807 HARRISON ST
Practice Address - Street 2:
Practice Address - City:COACHELLA
Practice Address - State:CA
Practice Address - Zip Code:92236-1524
Practice Address - Country:US
Practice Address - Phone:760-398-9288
Practice Address - Fax:760-398-9215
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52072122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist