Healthcare Provider Details

I. General information

NPI: 1962829143
Provider Name (Legal Business Name): KIM, HA, AND SAGONG DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

266 S HARVARD BLVD STE 220
LOS ANGELES CA
90004-3854
US

IV. Provider business mailing address

266 S HARVARD BLVD STE 220
LOS ANGELES CA
90004-3854
US

V. Phone/Fax

Practice location:
  • Phone: 213-999-7590
  • Fax: 213-797-5579
Mailing address:
  • Phone: 213-999-7950
  • Fax: 213-797-5579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. JEE HOON HA
Title or Position: VICE PRESIDENT
Credential: DDS
Phone: 213-550-8701