=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255873345
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHIWOO KIM D.M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2016
-----------------------------------------------------
Last Update Date | 01/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1502 W ARTESIA SQ APT B
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90248-4761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-590-5686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15823 WESTMINSTER WAY
-----------------------------------------------------
City | N SHORELINE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98113-4761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-590-5686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DE61424421
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DDS100351
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------