=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801624135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KWANG MIN LIM DMD A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2024
-----------------------------------------------------
Last Update Date | 07/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2020 COFFEE RD STE G2
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95355-2421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-312-9790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4608 OLD MILL CT
-----------------------------------------------------
City | SALIDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95368-8015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-312-9790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. KWANG MIN LIM
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 909-312-9790
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------