Provider Demographics
NPI:1710018254
Name:CHANGSOOK KIM DDS A DENTAL CORP
Entity Type:Organization
Organization Name:CHANGSOOK KIM DDS A DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CHANGSOOK
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-357-9909
Mailing Address - Street 1:1755 E HUNTINGTON DRIVE
Mailing Address - Street 2:#101
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010
Mailing Address - Country:US
Mailing Address - Phone:626-357-9909
Mailing Address - Fax:626-358-7245
Practice Address - Street 1:1755 E HUNTINGTON DR
Practice Address - Street 2:#101
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010
Practice Address - Country:US
Practice Address - Phone:626-357-9909
Practice Address - Fax:626-358-7245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39166CA122300000X
CA391661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty