Provider Demographics
NPI:1053625715
Name:KIM, KELLY YEON SU (DDS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:YEON SU
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30001 CROWN VALLEY PKWY
Mailing Address - Street 2:SUITE G
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-1723
Mailing Address - Country:US
Mailing Address - Phone:949-495-4245
Mailing Address - Fax:
Practice Address - Street 1:30001 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE G
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-1723
Practice Address - Country:US
Practice Address - Phone:949-495-4245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA580751223P0221X
NY0551141223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry