Provider Demographics
NPI:1053752204
Name:KIM, SON YONG (DDS)
Entity type:Individual
Prefix:DR
First Name:SON
Middle Name:YONG
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 1:50 LANSING ST
Mailing Address - Street 2:803
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94105-4601
Mailing Address - Country:US
Mailing Address - Phone:832-260-4821
Mailing Address - Fax:
Practice Address - Street 1:975 VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-1714
Practice Address - Country:US
Practice Address - Phone:650-480-5465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX292541223G0001X
CA642781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice