Healthcare Provider Details

I. General information

NPI: 1639963473
Provider Name (Legal Business Name): WILLIAM DAE WON KIM D.D.S. A DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 N VERMONT AVE
LOS ANGELES CA
90029-3519
US

IV. Provider business mailing address

2485 QUEENSBERRY RD
PASADENA CA
91104-3440
US

V. Phone/Fax

Practice location:
  • Phone: 323-522-3382
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM DAE WON KIM
Title or Position: DENTIST
Credential: DDS
Phone: 213-270-5432