Healthcare Provider Details

I. General information

NPI: 1962549519
Provider Name (Legal Business Name): GAMINCHI AND KIM DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15651 IMPERIAL HWY STE 105
LA MIRADA CA
90638-1600
US

IV. Provider business mailing address

15651 IMPERIAL HWY STE 105
LA MIRADA CA
90638-1600
US

V. Phone/Fax

Practice location:
  • Phone: 562-944-4745
  • Fax: 562-944-4745
Mailing address:
  • Phone: 562-944-4745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number43994
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number54813
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number41407
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number45238
License Number StateCA

VIII. Authorized Official

Name: EMMA KIM
Title or Position: CO-OWNER
Credential: D.M.D.
Phone: 562-944-4745