MEDICARE: JOHNNY K. KIM DDS INC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1619322294
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHNNY K. KIM DDS INC

Provider Business Mailing Address
First Line	:	936 CRENSHAW BLVD
Second Line	:	#100
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-1957
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1014 N VERMONT AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-2620
Country	:	US
Telephone Number	:	323-664-3400
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHNNY K KIM
Credential	:
Telephone Number	:	213-820-2989

Provider Enumeration Date	:	05/02/2016
Last Update Date	:	05/02/2016

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