=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184166498
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JASON KIM DDS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2016
-----------------------------------------------------
Last Update Date | 11/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2220 SMOKEWOOD AVE
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92831-1107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-853-5086
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2220 SMOKEWOOD AVE
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92831-1107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JASON KIM
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 714-853-5086
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 58856
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------