MEDICARE: STANLEY S KIM DENTAL CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1003445347
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STANLEY S KIM DENTAL CORP

Provider Business Mailing Address
First Line	:	4362 AVENIDA RIO DEL ORO
Second Line	:
City	:	YORBA LINDA
State	:	CA
Zip	:	92886-3011
Country	:	US
Telephone Number	:	714-904-1183
Fax Number	:

Provider Business Practice Location Address
First Line	:	4362 AVENIDA RIO DEL ORO
Second Line	:
City	:	YORBA LINDA
State	:	CA
Zip	:	92886-3011
Country	:	US
Telephone Number	:	714-904-1183
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	STANLEY KIM
Credential	:
Telephone Number	:	714-904-1183

Provider Enumeration Date	:	04/08/2020
Last Update Date	:	04/08/2020

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