MEDICARE: KIM & DIEP DENTAL CORPORATION

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	51573	CA

General Provider Information

NPI Number	:	1518404219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIM & DIEP DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	200 N BRADFORD AVE STE A
Second Line	:
City	:	PLACENTIA
State	:	CA
Zip	:	92870-5646
Country	:	US
Telephone Number	:	714-572-0170
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 N BRADFORD AVE STE A
Second Line	:
City	:	PLACENTIA
State	:	CA
Zip	:	92870-5646
Country	:	US
Telephone Number	:	714-572-0170
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHAEL DIEP
Credential	:	DDS
Telephone Number	:	714-335-0514

Provider Enumeration Date	:	01/19/2017
Last Update Date	:	01/19/2017

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