Healthcare Provider Details

I. General information

NPI: 1235002510
Provider Name (Legal Business Name): NAMGU KIM DMD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2025
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 S SUNSET AVE STE 208
WEST COVINA CA
91790-3410
US

IV. Provider business mailing address

3033 WILSHIRE BLVD APT 907
LOS ANGELES CA
90010-1008
US

V. Phone/Fax

Practice location:
  • Phone: 626-388-2621
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: NAMGU KIM
Title or Position: CEO
Credential:
Phone: 503-686-4289