Healthcare Provider Details

I. General information

NPI: 1275441008
Provider Name (Legal Business Name): NORTHSTAR PROFESSIONAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17075 CAGAN RIDGE BLVD STE 103
CLERMONT FL
34714-9619
US

IV. Provider business mailing address

17075 CAGAN RIDGE BLVD STE 103
CLERMONT FL
34714-9619
US

V. Phone/Fax

Practice location:
  • Phone: 818-523-7253
  • Fax:
Mailing address:
  • Phone: 818-523-7253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: SHIN KIM
Title or Position: PRESIDENT
Credential: DDS
Phone: 818-523-7253