=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063893295
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINNACLE PEAK ORAL SURGERY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2015
-----------------------------------------------------
Last Update Date | 06/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8575 E PRINCESS DR SUITE #217
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85255-5483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-342-8200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3626 WYANDOT ST
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80211-2951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-513-7371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | EUGENE JUNG KIM
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 303-513-7371
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
-----------------------------------------------------
License Number | D9251
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------