=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073938072
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HYUNGRIM OH, D.D.S., INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2014
-----------------------------------------------------
Last Update Date | 02/27/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14709 RINALDI ST
-----------------------------------------------------
City | SAN FERNANDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91340-4138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-361-1231
-----------------------------------------------------
Fax | 818-361-8487
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14709 RINALDI ST
-----------------------------------------------------
City | SAN FERNANDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91340-4138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-361-1231
-----------------------------------------------------
Fax | 818-361-8487
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/DENTIST
-----------------------------------------------------
Name | MRS. HYUNGRIM OH
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 818-361-1231
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 50501
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------