MEDICARE: AUDREY KIM DDS

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	122300000X	Dentist	61519	CA

General Provider Information

NPI Number	:	1053667832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDREY KIM DDS

Provider Business Mailing Address
First Line	:	17775 CALLE GRANADA
Second Line	:
City	:	MORGAN HILL
State	:	CA
Zip	:	95037-2992
Country	:	US
Telephone Number	:	716-374-3273
Fax Number	:

Provider Business Practice Location Address
First Line	:	930 SUNNYSLOPE RD STE B3
Second Line	:
City	:	HOLLISTER
State	:	CA
Zip	:	95023-5616
Country	:	US
Telephone Number	:	831-647-4627
Fax Number	:	831-637-7017

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2012
Last Update Date	:	09/29/2021

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