1134272362 NPI number — SUNG JOO C KIM DDS

Table of content: SUNG JOO C KIM DDS (NPI 1134272362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134272362 NPI number — SUNG JOO C KIM DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
SUNG JOO
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KIM
Provider Other First Name:
CHARLES
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1134272362
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
11/02/2015
NPI Reactivation Date:
11/02/2015

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1855 N EUCLID ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FULLERTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-693-3371
Provider Business Mailing Address Fax Number:
714-526-4671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1855 N EUCLID ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FULLERTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-693-3371
Provider Business Practice Location Address Fax Number:
714-526-4671
Provider Enumeration Date:
01/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DA 035824 , 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: B35824 01 . This is a "MEDICAL" identifier . This identifiers is of the category "OTHER".




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