Provider Demographics
NPI:1104962224
Name:DIPASQUALE, KIM JON (DDS MS)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:JON
Last Name:DIPASQUALE
Suffix:
Gender:M
Credentials:DDS MS
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Mailing Address - Street 1:500 SO ANAHEIM HILLS ROAD
Mailing Address - Street 2:SUITE 222
Mailing Address - City:ANAHEIM HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92807
Mailing Address - Country:US
Mailing Address - Phone:714-974-5906
Mailing Address - Fax:714-974-5982
Practice Address - Street 1:500 SO ANAHEIM HILLS ROAD
Practice Address - Street 2:SUITE 222
Practice Address - City:ANAHEIM HILLS
Practice Address - State:CA
Practice Address - Zip Code:92807
Practice Address - Country:US
Practice Address - Phone:714-974-5906
Practice Address - Fax:714-974-5982
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAD297221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT70460Medicare UPIN