Healthcare Provider Details

I. General information

NPI: 1598026874
Provider Name (Legal Business Name): KIM, JONG AND PARK DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 06/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 S LINCOLN AVE SUITE D
CORONA CA
92882-7137
US

IV. Provider business mailing address

341 S LINCOLN AVE SUITE D
CORONA CA
92882-7137
US

V. Phone/Fax

Practice location:
  • Phone: 951-520-8221
  • Fax:
Mailing address:
  • Phone: 951-520-8221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number39018
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number34505
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number49631
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number43494
License Number StateCA

VIII. Authorized Official

Name: RICHARD KIM
Title or Position: PARTINER
Credential: D.D.S
Phone: 951-520-8221