Provider Demographics
NPI:1114132107
Name:KEON-JUNG KIM PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:KEON-JUNG KIM PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEON-JUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-479-9876
Mailing Address - Street 1:3257 CAMINO DE LOS COCHES
Mailing Address - Street 2:#303
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-8966
Mailing Address - Country:US
Mailing Address - Phone:760-479-9876
Mailing Address - Fax:760-479-0028
Practice Address - Street 1:3257 CAMINO DE LOS COCHES
Practice Address - Street 2:#303
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-8966
Practice Address - Country:US
Practice Address - Phone:760-479-9876
Practice Address - Fax:760-479-0028
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEON-JUNG KIM DENTAL CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-11
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47919261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental