Healthcare Provider Details

I. General information

NPI: 1861186165
Provider Name (Legal Business Name): SAMUEL JUNWON KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2095 LINCOLN AVE # 201
ALTADENA CA
91001-5478
US

IV. Provider business mailing address

2552 E CRANE CT
ONTARIO CA
91761-8587
US

V. Phone/Fax

Practice location:
  • Phone: 626-610-4413
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113196
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: