=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073231346
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EUNICE G KIM DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2022
-----------------------------------------------------
Last Update Date | 08/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1643 N HACIENDA BLVD
-----------------------------------------------------
City | LA PUENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91744-1137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-505-2075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2525 WILSHIRE BLVD APT 713
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90057-3563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | EUNICE KIM
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 213-505-2075
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------