Provider Demographics
NPI:1518404219
Name:KIM & DIEP DENTAL CORPORATION
Entity Type:Organization
Organization Name:KIM & DIEP DENTAL CORPORATION
Other - Org Name:PLACENTIA DENTAL STUDIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DIEP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-335-0514
Mailing Address - Street 1:200 N BRADFORD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-5646
Mailing Address - Country:US
Mailing Address - Phone:714-572-0170
Mailing Address - Fax:
Practice Address - Street 1:200 N BRADFORD AVE STE A
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-5646
Practice Address - Country:US
Practice Address - Phone:714-572-0170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51573122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty