Provider Demographics
NPI:1932578101
Name:GRACE KIM DENTAL CORPORATION
Entity type:Organization
Organization Name:GRACE KIM DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:MIJIN
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-339-4600
Mailing Address - Street 1:1770 S BARRANCA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-5421
Mailing Address - Country:US
Mailing Address - Phone:626-339-4600
Mailing Address - Fax:626-339-4099
Practice Address - Street 1:1770 S BARRANCA AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-5421
Practice Address - Country:US
Practice Address - Phone:626-339-4600
Practice Address - Fax:626-339-4099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58445122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty