Provider Demographics
NPI:1134254683
Name:SIM, JUNG HYEB (DMD)
Entity type:Individual
Prefix:DR
First Name:JUNG
Middle Name:HYEB
Last Name:SIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 SAINT ANDREWS AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-1080
Mailing Address - Country:US
Mailing Address - Phone:213-700-1611
Mailing Address - Fax:310-830-3339
Practice Address - Street 1:602 W SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-6319
Practice Address - Country:US
Practice Address - Phone:310-830-3338
Practice Address - Fax:310-830-3339
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50371122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD50371Medicare ID - Type UnspecifiedRENDERING PROVIDER #
CAG93082-01Medicare ID - Type UnspecifiedDENTI-CAL