MEDICARE: DR. HONG KU KIM D.D.S.

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	49909	CA

General Provider Information

NPI Number	:	1285650275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HONG KU KIM D.D.S.

Provider Business Mailing Address
First Line	:	2379 E COLORADO BLVD
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91107-4263
Country	:	US
Telephone Number	:	626-584-7017
Fax Number	:	626-584-9227

Provider Business Practice Location Address
First Line	:	2379 E COLORADO BLVD
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91107-4263
Country	:	US
Telephone Number	:	626-584-7017
Fax Number	:	626-584-9227

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

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	07/08/2007

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