Healthcare Provider Details

I. General information

NPI: 1518404219
Provider Name (Legal Business Name): KIM & DIEP DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N BRADFORD AVE STE A
PLACENTIA CA
92870-5646
US

IV. Provider business mailing address

200 N BRADFORD AVE STE A
PLACENTIA CA
92870-5646
US

V. Phone/Fax

Practice location:
  • Phone: 714-572-0170
  • Fax:
Mailing address:
  • Phone: 714-572-0170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number51573
License Number StateCA

VIII. Authorized Official

Name: MICHAEL DIEP
Title or Position: PRESIDENT
Credential: DDS
Phone: 714-335-0514