Healthcare Provider Details

I. General information

NPI: 1588896740
Provider Name (Legal Business Name): JAMES KIM DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3140 S DURANGO DR STE 100
LAS VEGAS NV
89117-9189
US

IV. Provider business mailing address

526 S TONOPAH DR STE. 200
LAS VEGAS NV
89106-4043
US

V. Phone/Fax

Practice location:
  • Phone: 917-407-8141
  • Fax:
Mailing address:
  • Phone: 702-291-2031
  • Fax: 702-366-1483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number58517
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number127414
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS2-141C
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number58517
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: