=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255084422
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DREAM HIGH DENTAL ANESTHESIA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2022
-----------------------------------------------------
Last Update Date | 04/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 144 BOSTON AVE
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06610-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 475-422-8761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1979 HILLMAN ST
-----------------------------------------------------
City | TULARE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93274-1601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-732-4279
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST ANESTHESIOLOGIST
-----------------------------------------------------
Name | ROSY KIM
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 909-296-2338
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0004X
-----------------------------------------------------
Taxonomy Name | Dental Anesthesiology
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------