=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548754260
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEACE KIM DENTISTRY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2018
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3840 WOODRUFF AVE STE 107
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90808-2148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-421-3764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 LONGBOURN AISLE
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92603-5722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO, DDS
-----------------------------------------------------
Name | PEACE KIM
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 949-232-7965
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 63279
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------