1386851525 NPI number — S.S. KIM, D.D.S. INC.

Table of content: (NPI 1386851525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386851525 NPI number — S.S. KIM, D.D.S. INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
S.S. KIM, D.D.S. INC.
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:
GP DENTAL CENTER
Provider Other Organization Name Type Code:
3
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:
1386851525
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1410 N GAREY AVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
POMONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91767-3810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-623-8535
Provider Business Mailing Address Fax Number:
909-623-8230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1410 N GAREY AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
POMONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91767-3810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-623-8535
Provider Business Practice Location Address Fax Number:
909-623-8230
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TRUONG-KIM
Authorized Official First Name:
NINA
Authorized Official Middle Name:
Authorized Official Title or Position:
REGIONAL MANAGER
Authorized Official Telephone Number:
951-377-2278

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  39026 , 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)

  • Identifier: B39026-01 . This is a "DENTICAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 829626 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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