Healthcare Provider Details

I. General information

NPI: 1225635600
Provider Name (Legal Business Name): TAE KYUN HA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12271 LA MIRADA BLVD STE 201
LA MIRADA CA
90638-1336
US

IV. Provider business mailing address

4813 OAKWOOD AVE UNIT 104
LOS ANGELES CA
90004-3559
US

V. Phone/Fax

Practice location:
  • Phone: 562-445-3555
  • Fax:
Mailing address:
  • Phone: 818-445-1899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number105470
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number105470
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: