1215159389 NPI number — WYNDHAMSMITHA ND KIM, A PROFESSIONAL DENTAL CORPORATION

Table of content: (NPI 1215159389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215159389 NPI number — WYNDHAMSMITHA ND KIM, A PROFESSIONAL DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYNDHAMSMITHA ND KIM, A PROFESSIONAL DENTAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
VALENCIA DENTAL CARE
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215159389
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28097 SMYTH DRIVE
Provider Second Line Business Mailing Address:
SUITE A & C
Provider Business Mailing Address City Name:
VALENCIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91355
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-291-1412
Provider Business Mailing Address Fax Number:
661-291-1423

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23838 VALENCIA BLVD.
Provider Second Line Business Practice Location Address:
SUITE #301
Provider Business Practice Location Address City Name:
VALENCIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-291-1412
Provider Business Practice Location Address Fax Number:
661-291-1423
Provider Enumeration Date:
05/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WYNDHAMSMITH
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
661-291-1412

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  28413 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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