=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497979280
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANG C PAIK DDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3811 BEDFORD CANYON RD SUITE 105
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-270-0211
-----------------------------------------------------
Fax | 951-270-0702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3811 BEDFORD CANYON RD SUITE 105
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-270-0211
-----------------------------------------------------
Fax | 951-270-0702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DENTIST
-----------------------------------------------------
Name | SANG CHURL PAIK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 951-270-0211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 41861
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------