=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649733015
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUN DENTAL 4 KIDS 3
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2019
-----------------------------------------------------
Last Update Date | 04/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2864 E FLORENCE AVE # 3
-----------------------------------------------------
City | HUNTINGTON PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90255-5749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-619-5880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6383 ATLANTIC AVE
-----------------------------------------------------
City | BELL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90201-1227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-619-5880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | JOHN YOO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 310-619-5880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------