Provider Demographics
NPI:1043439953
Name:JAE G. KIM PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:JAE G. KIM PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:INWOO
Authorized Official - Middle Name:
Authorized Official - Last Name:YI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:213-385-9710
Mailing Address - Street 1:2500 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-4303
Mailing Address - Country:US
Mailing Address - Phone:213-385-9710
Mailing Address - Fax:213-385-9343
Practice Address - Street 1:2500 WILSHIRE BLVD
Practice Address - Street 2:SUITE 1100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-4303
Practice Address - Country:US
Practice Address - Phone:213-385-9710
Practice Address - Fax:213-385-9343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA414391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA521373Medicare UPIN