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General NPI Number Information
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NPI Number | 1033372958
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Entity Type | Organization
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Legal Business Name | MOUNT DORA DENTAL & DENTURES
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Dates
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Enumeration Date | 07/10/2008
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Last Update Date | 02/22/2011
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Provider Practice Location Address
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Address Line | 2781 W OLD HIGHWAY 441 #24A
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City | MOUNT DORA
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State | FL
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Zip | 32757
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Country | US
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Telephone | 352-385-1971
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Fax | 352-729-2239
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Provider Business Mailing Address
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Address Line | 2781 W OLD HIGHWAY 441 #24A
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City | MOUNT DORA
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State | FL
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Zip | 32757
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Country | US
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Telephone | 352-385-1971
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Fax | 325-729-2239
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Authorized Official
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Title or Position | OWNER
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Name | DR. SOOK JA KIM
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Credential | D.M.D
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Telephone | 352-385-1971
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 14970
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License Number State | FL
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