Healthcare Provider Details

I. General information

NPI: 1467393876
Provider Name (Legal Business Name): MINKI KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 E MANCHESTER AVE
LOS ANGELES CA
90003-3525
US

IV. Provider business mailing address

825 S HILL ST APT 3007
LOS ANGELES CA
90014-3298
US

V. Phone/Fax

Practice location:
  • Phone: 323-753-3000
  • Fax:
Mailing address:
  • Phone: 512-534-7690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113300
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: