Provider Demographics
NPI:1194103093
Name:KYUNG MYUN KIM DDS CORPORATION
Entity type:Organization
Organization Name:KYUNG MYUN KIM DDS CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:YANG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-505-2010
Mailing Address - Street 1:24953 PASEO DE VALENCIA STE 13C
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-4344
Mailing Address - Country:US
Mailing Address - Phone:949-770-4275
Mailing Address - Fax:949-770-0538
Practice Address - Street 1:24953 PASEO DE VALENCIA STE 13C
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-4344
Practice Address - Country:US
Practice Address - Phone:949-770-4275
Practice Address - Fax:949-770-0538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-12
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA118151223G0001X
CA423421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93667-01Medicaid