Provider Demographics
NPI:1932315298
Name:KEON-JUNG KIM DENTAL CORPORATION
Entity Type:Organization
Organization Name:KEON-JUNG KIM DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEON-JUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-679-6000
Mailing Address - Street 1:2492 WALNUT AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6960
Mailing Address - Country:US
Mailing Address - Phone:949-679-6000
Mailing Address - Fax:949-679-6001
Practice Address - Street 1:2492 WALNUT AVE STE 200
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6960
Practice Address - Country:US
Practice Address - Phone:949-679-6000
Practice Address - Fax:949-679-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47919261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental