Healthcare Provider Details

I. General information

NPI: 1629629134
Provider Name (Legal Business Name): ANSONY KIM, DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2591 MAIN ST
OAKLEY CA
94561-1854
US

IV. Provider business mailing address

PO BOX 4604
WALNUT CREEK CA
94596-0604
US

V. Phone/Fax

Practice location:
  • Phone: 925-690-5437
  • Fax: 925-690-5438
Mailing address:
  • Phone: 510-334-3622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ANSONY JIN KIM
Title or Position: OWNER
Credential: DDS
Phone: 510-334-3622