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General NPI Number Information
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NPI Number | 1063874329
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Entity Type | Organization
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Legal Business Name | DENTISTAR COMPREHENSIVE DENTAL CARE, INC.
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Dates
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Enumeration Date | 03/25/2016
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Last Update Date | 03/25/2016
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Provider Practice Location Address
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Address Line | 111 DEERWOOD RD SUITE 350
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City | SAN RAMON
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State | CA
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Zip | 94583-4409
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Country | US
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Telephone | 925-718-8970
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Fax | 925-718-8971
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Provider Business Mailing Address
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Address Line | 111 DEERWOOD RD SUITE 350
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City | SAN RAMON
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State | CA
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Zip | 94583-4409
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Country | US
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Telephone | 925-718-8970
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Fax | 925-718-8971
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Authorized Official
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Title or Position | PRESIDENT
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Name | STEVE G KIM
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Credential | D.D.S.
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Telephone | 310-963-1316
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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 | 58619
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License Number State | CA
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