Healthcare Provider Details

I. General information

NPI: 1972777829
Provider Name (Legal Business Name): SAE ROM KIM.DDS.INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N IMPERIAL AVE
CALEXICO CA
92231-3209
US

IV. Provider business mailing address

2300 N IMPERIAL AVE
CALEXICO CA
92231-3209
US

V. Phone/Fax

Practice location:
  • Phone: 760-357-1632
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number52739
License Number StateCA

VIII. Authorized Official

Name: SAE ROM KIM
Title or Position: PRESIDENT
Credential:
Phone: 760-357-1632