=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447858766
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN YUNOUK KIM DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2020
-----------------------------------------------------
Last Update Date | 10/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 E BUENA VISTA ST
-----------------------------------------------------
City | BARSTOW
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92311-2803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-460-4999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11431 MAGNOLIA AVE APT 106
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92505-4812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-838-8701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 86493
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------