Provider Demographics
NPI:1770821423
Name:TED T. IM, DDS, INC.
Entity Type:Organization
Organization Name:TED T. IM, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TED
Authorized Official - Middle Name:
Authorized Official - Last Name:IM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-242-6242
Mailing Address - Street 1:23205 SUNNYMEAD BLVD
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5246
Mailing Address - Country:US
Mailing Address - Phone:951-242-6242
Mailing Address - Fax:951-242-4782
Practice Address - Street 1:23205 SUNNYMEAD BLVD
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5246
Practice Address - Country:US
Practice Address - Phone:951-242-6242
Practice Address - Fax:951-242-4782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-30
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA409501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD40950Medicaid