Provider Demographics
NPI:1033562939
Name:KIM, SCARLET (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCARLET
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20028 EMERALD MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-3506
Mailing Address - Country:US
Mailing Address - Phone:909-631-6653
Mailing Address - Fax:
Practice Address - Street 1:24481 ALICIA PKWY # 3
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-4534
Practice Address - Country:US
Practice Address - Phone:949-586-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA000000001223G0001X
ORD106351223G0001X
CA1047591223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPENDINGMedicaid