Healthcare Provider Details

I. General information

NPI: 1821574864
Provider Name (Legal Business Name): IL-SEON KIM, DDS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1722 DESIRE AVE 201
ROWLAND HEIGHTS CA
91748
US

IV. Provider business mailing address

1722 DESIRE AVE
ROWLAND HEIGHTS CA
91748-2968
US

V. Phone/Fax

Practice location:
  • Phone: 626-964-1884
  • Fax:
Mailing address:
  • Phone: 626-964-1884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number33302
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: IL SEON KIM
Title or Position: OWNER
Credential: DDS
Phone: 626-964-1884