Healthcare Provider Details

I. General information

NPI: 1891069266
Provider Name (Legal Business Name): UNITED DENTAL NORTHRIDGE CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10149 RESEDA BLVD
NORTHRIDGE CA
91324-1454
US

IV. Provider business mailing address

10149 RESEDA BLVD
NORTHRIDGE CA
91324-1454
US

V. Phone/Fax

Practice location:
  • Phone: 714-525-6900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: JEONG HOON KIM
Title or Position: CEO, CFO, & SECRETARY
Credential:
Phone: 714-525-6900