Healthcare Provider Details

I. General information

NPI: 1003388307
Provider Name (Legal Business Name): JAMES YOUNG KIM DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2018
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74420 HIGHWAY 111 STE 1
PALM DESERT CA
92260-4144
US

IV. Provider business mailing address

74420 HIGHWAY 111 STE 1
PALM DESERT CA
92260-4144
US

V. Phone/Fax

Practice location:
  • Phone: 760-779-5662
  • Fax: 760-779-5683
Mailing address:
  • Phone: 760-779-5662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMES YOUNG KIM
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 760-779-5662