Provider Demographics
NPI:1255873345
Name:KIM, SHIWOO (DMD)
Entity type:Individual
Prefix:DR
First Name:SHIWOO
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15823 WESTMINSTER WAY
Mailing Address - Street 2:
Mailing Address - City:N SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98113-4761
Mailing Address - Country:US
Mailing Address - Phone:213-590-5686
Mailing Address - Fax:
Practice Address - Street 1:1502 W ARTESIA SQ APT B
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4761
Practice Address - Country:US
Practice Address - Phone:213-590-5686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-07
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE614244211223S0112X
CADDS100351122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No122300000XDental ProvidersDentist