Provider Demographics
NPI:1730742115
Name:KIM, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 E OCEAN BLVD UNIT 301
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-5255
Mailing Address - Country:US
Mailing Address - Phone:703-505-6922
Mailing Address - Fax:
Practice Address - Street 1:15266 GOLDENWEST ST
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-6169
Practice Address - Country:US
Practice Address - Phone:714-379-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-21
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1055241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice