Provider Demographics
NPI:1861889347
Name:KIM, SANG WOO
Entity type:Individual
Prefix:
First Name:SANG WOO
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 1:410 S GLENDORA AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-6207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 S GLENDORA AVE STE 220
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-6207
Practice Address - Country:US
Practice Address - Phone:626-914-4587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1035411223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program