Provider Demographics
NPI:1104336478
Name:LOUIS M KIM, A PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:LOUIS M KIM, A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-900-8521
Mailing Address - Street 1:1824 AVONDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1378
Mailing Address - Country:US
Mailing Address - Phone:916-900-8521
Mailing Address - Fax:916-900-8526
Practice Address - Street 1:1824 AVONDALE AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-1378
Practice Address - Country:US
Practice Address - Phone:916-900-8521
Practice Address - Fax:916-900-8526
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOUIS KIM DDS INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53231261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1174711522Medicaid