Provider Demographics
NPI:1457476137
Name:RA AND KIM DENTAL CORP
Entity Type:Organization
Organization Name:RA AND KIM DENTAL CORP
Other - Org Name:LAKESIDE DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:JAE
Authorized Official - Last Name:RA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-866-0606
Mailing Address - Street 1:PO BOX 6951
Mailing Address - Street 2:42002 FOX FARM ROAD #101
Mailing Address - City:BIG BEAR LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92315-6951
Mailing Address - Country:US
Mailing Address - Phone:909-866-0606
Mailing Address - Fax:909-866-5546
Practice Address - Street 1:42002 FOX FARM ROAD #101
Practice Address - Street 2:
Practice Address - City:BIG BEAR LAKE
Practice Address - State:CA
Practice Address - Zip Code:92315-6951
Practice Address - Country:US
Practice Address - Phone:909-866-0606
Practice Address - Fax:909-866-5546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92304-01Medicare ID - Type UnspecifiedDENTICAL ID