=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477766756
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOO HYUN LIM D.M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 11/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4631 HILLARD AVE
-----------------------------------------------------
City | LA CANADA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91011-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-582-1707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4631 HILLARD AVE
-----------------------------------------------------
City | LA CANADA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91011-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-582-1707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 60072
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------