Healthcare Provider Details

I. General information

NPI: 1285287110
Provider Name (Legal Business Name): JAE EUN KIM DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8819 WHITTIER BLVD STE 102
PICO RIVERA CA
90660-2673
US

IV. Provider business mailing address

8819 WHITTIER BLVD STE 102
PICO RIVERA CA
90660-2673
US

V. Phone/Fax

Practice location:
  • Phone: 562-699-1000
  • Fax: 562-699-1099
Mailing address:
  • Phone: 562-699-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number104068
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number104068
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier104068
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerAVAILITY
# 2
Identifier104068
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: