=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578947123
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HKDDS SMILE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2015
-----------------------------------------------------
Last Update Date | 07/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13048 RESEARCH BLVD STE B
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78750-3205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-257-2828
-----------------------------------------------------
Fax | 512-257-2831
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13048 RESEARCH BLVD STE B
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78750-3205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-257-2828
-----------------------------------------------------
Fax | 512-257-2831
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | TORI KIM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 213-300-0506
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------