Provider Demographics
NPI:1194116475
Name:HIEM DENTAL CORP
Entity type:Organization
Organization Name:HIEM DENTAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:DONGSUK
Authorized Official - Middle Name:
Authorized Official - Last Name:KWAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-899-0488
Mailing Address - Street 1:10214 N TATUM BLVD
Mailing Address - Street 2:B600
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-4231
Mailing Address - Country:US
Mailing Address - Phone:602-899-0488
Mailing Address - Fax:602-884-8240
Practice Address - Street 1:10214 N TATUM BLVD
Practice Address - Street 2:B600
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-4231
Practice Address - Country:US
Practice Address - Phone:602-899-0488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-09
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZF0005421223G0001X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty