Healthcare Provider Details

I. General information

NPI: 1770084972
Provider Name (Legal Business Name): HYOUNGWOOK KIM DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 S BREA CANYON RD STE 222
DIAMOND BAR CA
91765-3785
US

IV. Provider business mailing address

3333 S BREA CANYON RD STE 222
DIAMOND BAR CA
91765-3785
US

V. Phone/Fax

Practice location:
  • Phone: 909-594-7999
  • Fax: 909-594-9997
Mailing address:
  • Phone: 909-594-7999
  • Fax: 909-594-9997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number51088
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number51088
License Number StateCA

VIII. Authorized Official

Name: HYOUNGWOOK KIM
Title or Position: PRESIDENT
Credential: DDS
Phone: 562-860-7999