Healthcare Provider Details

I. General information

NPI: 1982118469
Provider Name (Legal Business Name): JENNY H KIM RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10602 CHAPMAN AVE STE 200
GARDEN GROVE CA
92840-3147
US

IV. Provider business mailing address

281 FOLLYHATCH
IRVINE CA
92618-1051
US

V. Phone/Fax

Practice location:
  • Phone: 714-537-0700
  • Fax: 714-537-0733
Mailing address:
  • Phone: 949-679-7606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number19011
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: