Healthcare Provider Details

I. General information

NPI: 1386054674
Provider Name (Legal Business Name): SOYEON KIM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2509 W MCFADDEN AVE SUITE-E
SANTA ANA CA
92704-2747
US

IV. Provider business mailing address

2509 W MCFADDEN AVE STE E
SANTA ANA CA
92704-2747
US

V. Phone/Fax

Practice location:
  • Phone: 714-835-8797
  • Fax: 714-835-8798
Mailing address:
  • Phone: 714-835-8797
  • Fax: 714-835-8798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number54627
License Number StateCA

VIII. Authorized Official

Name: SOYEON KIM
Title or Position: DENTIST/OWNER
Credential: D.M.D
Phone: 714-835-8797