Provider Demographics
NPI:1902986250
Name:KIM, JOHN Y (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:Y
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14545 W GRAND AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7278
Mailing Address - Country:US
Mailing Address - Phone:623-975-9775
Mailing Address - Fax:623-975-9449
Practice Address - Street 1:14545 W GRAND AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7278
Practice Address - Country:US
Practice Address - Phone:623-975-9775
Practice Address - Fax:623-975-9449
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5654122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist