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General NPI Number Information
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NPI Number | 1114132107
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Entity Type | Organization
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Legal Business Name | KEON-JUNG KIM PROFESSIONAL DENTAL CORPORATION
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Dates
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Enumeration Date | 05/11/2007
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Last Update Date | 08/23/2007
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Provider Practice Location Address
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Address Line | 3257 CAMINO DE LOS COCHES #303
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City | CARLSBAD
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State | CA
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Zip | 92009-8966
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Country | US
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Telephone | 760-479-9876
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Fax | 760-479-0028
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Provider Business Mailing Address
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Address Line | 3257 CAMINO DE LOS COCHES #303
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City | CARLSBAD
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State | CA
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Zip | 92009-8966
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Country | US
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Telephone | 760-479-9876
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Fax | 760-479-0028
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Authorized Official
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Title or Position | OWNER
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Name | KEON-JUNG KIM
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Credential | D.D.S.
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Telephone | 760-479-9876
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 47919
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License Number State | CA
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