Healthcare Provider Details

I. General information

NPI: 1295979532
Provider Name (Legal Business Name): MICHELLE K. KIM D.D.S. CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2009
Last Update Date: 08/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2245 E. COLORADO BLVD. SUITE 201
PASADENA CA
91107
US

IV. Provider business mailing address

2245 E. COLORADO BLVD. SUITE 201
PASADENA CA
91107
US

V. Phone/Fax

Practice location:
  • Phone: 626-449-3367
  • Fax: 626-449-3376
Mailing address:
  • Phone: 626-449-3367
  • Fax: 626-449-3376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number42670
License Number StateCA

VIII. Authorized Official

Name: MRS. MICHELLE KYONGAH KIM
Title or Position: PRESIDENT/OWNER
Credential: D.D.S.
Phone: 626-449-3367