Provider Demographics
NPI:1376964064
Name:PETER KIM, D.D.S., PROFESSIONAL CORP.
Entity Type:Organization
Organization Name:PETER KIM, D.D.S., PROFESSIONAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:UNG KWON
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-402-4411
Mailing Address - Street 1:11899 DEL AMO BLVD
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-7605
Mailing Address - Country:US
Mailing Address - Phone:562-402-4411
Mailing Address - Fax:562-402-5052
Practice Address - Street 1:11899 DEL AMO BLVD
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-7605
Practice Address - Country:US
Practice Address - Phone:562-402-4411
Practice Address - Fax:562-402-5052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-23
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49769305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization