=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366355000
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY KID'S DENTIST OF LAKE FOREST, PROF. CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2026
-----------------------------------------------------
Last Update Date | 09/24/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23708 EL TORO RD STE B
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92630-8907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-234-6799
-----------------------------------------------------
Fax | 949-238-2620
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 660041
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75266-0041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-845-8890
-----------------------------------------------------
Fax | 303-952-0892
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GRACE NOH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 949-234-6799
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------