Healthcare Provider Details

I. General information

NPI: 1598989063
Provider Name (Legal Business Name): BRIAN KIM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12721 NEWPORT AVE STE 1
TUSTIN CA
92780-8031
US

IV. Provider business mailing address

12721 NEWPORT AVE STE 1
TUSTIN CA
92780-8031
US

V. Phone/Fax

Practice location:
  • Phone: 714-730-8070
  • Fax: 714-730-8112
Mailing address:
  • Phone: 714-730-8070
  • Fax: 714-730-8112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number50765
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number50765
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number50765
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: