=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386054674
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOYEON KIM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2014
-----------------------------------------------------
Last Update Date | 08/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2509 W MCFADDEN AVE SUITE-E
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92704-2747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-835-8797
-----------------------------------------------------
Fax | 714-835-8798
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2509 W MCFADDEN AVE STE E
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92704-2747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-835-8797
-----------------------------------------------------
Fax | 714-835-8798
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | SOYEON KIM
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 714-835-8797
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number | 54627
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------