1578808788 NPI number — YOUNG RAE KIM, DDS INC

Table of content: (NPI 1578808788)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578808788 NPI number — YOUNG RAE KIM, DDS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YOUNG RAE KIM, DDS 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:
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:
1578808788
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12144 E. CARSON STREET
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
HAWAIIAN GARDENS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90716-1171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-982-1380
Provider Business Mailing Address Fax Number:
562-982-1383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12144 E. CARSON STREET
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
HAWAIIAN GARDENS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90716-1171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-982-1380
Provider Business Practice Location Address Fax Number:
562-982-1383
Provider Enumeration Date:
11/29/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KIM
Authorized Official First Name:
YOUNG RAE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
562-982-1380

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  59862 , 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: 1205137999 . This is a "DENTICAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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