Provider Demographics
NPI:1225635600
Name:HA, TAE KYUN (DDS)
Entity Type:Individual
Prefix:
First Name:TAE KYUN
Middle Name:
Last Name:HA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4813 OAKWOOD AVE UNIT 104
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3559
Mailing Address - Country:US
Mailing Address - Phone:818-445-1899
Mailing Address - Fax:
Practice Address - Street 1:12271 LA MIRADA BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1336
Practice Address - Country:US
Practice Address - Phone:562-445-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1054701223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice