=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316145659
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEAN YOUNG-YUM KIM D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2007
-----------------------------------------------------
Last Update Date | 07/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 GREGORY LN
-----------------------------------------------------
City | PLEASANT HILL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94523-2800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-689-1020
-----------------------------------------------------
Fax | 925-689-1028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5085 CAMPION DR
-----------------------------------------------------
City | SAN RAMON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94582-5228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-648-2829
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 45797
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------