Provider Demographics
NPI:1164250312
Name:HOANG, KIM
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:HOANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18330 N 79TH AVE APT 2013
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2370 W HAPPY VALLEY RD
Practice Address - Street 2:STE 1073
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085
Practice Address - Country:US
Practice Address - Phone:623-281-1021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-22
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD012249122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist