=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700115342
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SONG KYUN KIM D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2009
-----------------------------------------------------
Last Update Date | 11/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4635 E AVENUE S STE C102-103
-----------------------------------------------------
City | PALMDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-349-8280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4635 E AVENUE S STE C102-103
-----------------------------------------------------
City | PALMDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-349-8280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 58863
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------