=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467055566
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRUSMILE DENTAL HYGIENE PRACTICE OF KIM, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2020
-----------------------------------------------------
Last Update Date | 03/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 66 S SAN GORGONIO AVE STE 5
-----------------------------------------------------
City | BANNING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92220-6020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-922-4975
-----------------------------------------------------
Fax | 951-922-4976
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 66 S SAN GORGONIO AVE STE 5
-----------------------------------------------------
City | BANNING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92220-6020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-553-8235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARIA ANTONETTE KIM
-----------------------------------------------------
Credential | RDHAP
-----------------------------------------------------
Telephone | 951-922-4975
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------