=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023778768
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIANE KIM DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2021
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19725 HIGHWAY 59 N
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77338-3566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-972-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19725 HIGHWAY 59 N
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77338-3566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DIANE KIM
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 646-369-4078
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------