1861034944 NPI number — JONGGUON KIM DDS DENTAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861034944 NPI number — JONGGUON KIM DDS DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JONGGUON KIM DDS 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:
Provider Other Organization Name Type Code:
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:
1861034944
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4128 POMPIA WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92883-0687
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-342-3009
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1973 FOOTHILL PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
CORONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-256-4556
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/10/2019

Additional Information

Authorized Official

Authorized Official Last Name:
KIM
Authorized Official First Name:
JONGGUON
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
951-256-4556

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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