=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235682790
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YK DENTAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2016
-----------------------------------------------------
Last Update Date | 08/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5417D BACKLICK RD
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22151-3915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-988-3386
-----------------------------------------------------
Fax | 703-988-3389
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5417D BACKLICK RD
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22151-3915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-988-3386
-----------------------------------------------------
Fax | 703-988-3389
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/DENTIST
-----------------------------------------------------
Name | DR. YOUNGDAE KIM
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 703-988-3386
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 0401415145
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------