Provider Demographics
NPI:1215159389
Name:WYNDHAMSMITHA ND KIM, A PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:WYNDHAMSMITHA ND KIM, A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:WYNDHAMSMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:661-291-1412
Mailing Address - Street 1:28097 SMYTH DRIVE
Mailing Address - Street 2:SUITE A & C
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355
Mailing Address - Country:US
Mailing Address - Phone:661-291-1412
Mailing Address - Fax:661-291-1423
Practice Address - Street 1:23838 VALENCIA BLVD.
Practice Address - Street 2:SUITE #301
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355
Practice Address - Country:US
Practice Address - Phone:661-291-1412
Practice Address - Fax:661-291-1423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28413122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty