Provider Demographics
NPI:1710867031
Name:KIM, ELIANA YAENA
Entity type:Individual
Prefix:
First Name:ELIANA
Middle Name:YAENA
Last Name:KIM
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 1:4000 COBBLESTONE LN
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-2600
Mailing Address - Country:US
Mailing Address - Phone:916-508-9953
Mailing Address - Fax:
Practice Address - Street 1:20300 W VALLEY BLVD STE A
Practice Address - Street 2:
Practice Address - City:TEHACHAPI
Practice Address - State:CA
Practice Address - Zip Code:93561-8609
Practice Address - Country:US
Practice Address - Phone:661-469-0020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-05
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112339122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist