Healthcare Provider Details

I. General information

NPI: 1306323035
Provider Name (Legal Business Name): SEAN KIM, DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2018
Last Update Date: 07/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 N LAKE AVE
PASADENA CA
91104-3768
US

IV. Provider business mailing address

936 CRENSHAW BLVD STE 101
LOS ANGELES CA
90019-1948
US

V. Phone/Fax

Practice location:
  • Phone: 626-584-1800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number102689
License Number StateCA

VIII. Authorized Official

Name: DR. SEAN SUNYOTO
Title or Position: DENTIST
Credential: DDS
Phone: 626-510-2606