Healthcare Provider Details

I. General information

NPI: 1497974448
Provider Name (Legal Business Name): SEAN YOUNGSAN KIM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 05/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5115 N DYSART RD STE 218
LITCHFIELD PARK AZ
85340
US

IV. Provider business mailing address

13706 W BELL RD STE 2
SURPRISE AZ
85374
US

V. Phone/Fax

Practice location:
  • Phone: 623-536-0900
  • Fax: 623-536-0920
Mailing address:
  • Phone: 623-584-9910
  • Fax: 623-584-9940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4311
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD4311
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: