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General NPI Number Information
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NPI Number | 1043468267
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Entity Type | Organization
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Legal Business Name | MIRACLE MILE COMPREHENSIVE DENTAL CENTER
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Dates
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Enumeration Date | 08/29/2008
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 5455 WILSHIRE BLVD SUITE # 850
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City | LOS ANGELES
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State | CA
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Zip | 90036-4201
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Country | US
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Telephone | 323-930-4600
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Fax | 323-930-4604
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Provider Business Mailing Address
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Address Line | 5455 WILSHIRE BLVD SUITE # 850
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City | LOS ANGELES
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State | CA
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Zip | 90036-4201
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Country | US
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Telephone | 323-930-4600
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Fax | 323-930-4604
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Authorized Official
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Title or Position | CEO
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Name | DR. JANG WOOK KIM
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Credential | D.D.S.
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Telephone | 323-930-4600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 5015001
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License Number State | CA
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