Healthcare Provider Details

I. General information

NPI: 1285168641
Provider Name (Legal Business Name): HENNA KIM DENTAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E COLORADO ST # 200
GLENDALE CA
91205-1607
US

IV. Provider business mailing address

2060 BARNETT RD
LOS ANGELES CA
90032-4102
US

V. Phone/Fax

Practice location:
  • Phone: 949-697-3232
  • Fax:
Mailing address:
  • Phone: 949-697-3232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number58338
License Number StateCA

VIII. Authorized Official

Name: DR. HENNA KIM
Title or Position: PRESIDENT/ORTHODONTIST
Credential:
Phone: 949-697-3232