Provider Demographics
NPI:1043468267
Name:MIRACLE MILE COMPREHENSIVE DENTAL CENTER
Entity Type:Organization
Organization Name:MIRACLE MILE COMPREHENSIVE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JANG WOOK
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-930-4600
Mailing Address - Street 1:5455 WILSHIRE BLVD
Mailing Address - Street 2:SUITE # 850
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-4201
Mailing Address - Country:US
Mailing Address - Phone:323-930-4600
Mailing Address - Fax:323-930-4604
Practice Address - Street 1:5455 WILSHIRE BLVD
Practice Address - Street 2:SUITE # 850
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4201
Practice Address - Country:US
Practice Address - Phone:323-930-4600
Practice Address - Fax:323-930-4604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50150011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD5015001Medicaid
CA1801920921OtherINDIVIDUAL NPI
CABK8040773OtherDEA