Healthcare Provider Details

I. General information

NPI: 1780093203
Provider Name (Legal Business Name): DUSTIN KIM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 05/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 CALIFORNIA AVE STE 400B
BAKERSFIELD CA
93309-7081
US

IV. Provider business mailing address

4900 CALIFORNIA AVE STE 400B
BAKERSFIELD CA
93309-7081
US

V. Phone/Fax

Practice location:
  • Phone: 661-459-7049
  • Fax:
Mailing address:
  • Phone: 661-459-7049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number64398
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2014024597
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: