1710018254 NPI number — CHANGSOOK KIM DDS A DENTAL CORP

Table of content: (NPI 1710018254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710018254 NPI number — CHANGSOOK KIM DDS A DENTAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHANGSOOK KIM DDS A DENTAL CORP
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:
1710018254
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1755 E HUNTINGTON DRIVE
Provider Second Line Business Mailing Address:
#101
Provider Business Mailing Address City Name:
DUARTE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-357-9909
Provider Business Mailing Address Fax Number:
626-358-7245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1755 E HUNTINGTON DR
Provider Second Line Business Practice Location Address:
#101
Provider Business Practice Location Address City Name:
DUARTE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-357-9909
Provider Business Practice Location Address Fax Number:
626-358-7245
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KIM
Authorized Official First Name:
CHANGSOOK
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
626-357-9909

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  39166CA , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 39166 , 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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