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General NPI Number Information
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NPI Number | 1932578101
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Entity Type | Organization
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Legal Business Name | GRACE KIM DENTAL CORPORATION
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Dates
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Enumeration Date | 09/17/2015
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Last Update Date | 09/17/2015
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Provider Practice Location Address
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Address Line | 1770 S BARRANCA AVE
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City | GLENDORA
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State | CA
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Zip | 91740-5421
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Country | US
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Telephone | 626-339-4600
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Fax | 626-339-4099
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Provider Business Mailing Address
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Address Line | 1770 S BARRANCA AVE
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City | GLENDORA
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State | CA
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Zip | 91740-5421
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Country | US
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Telephone | 626-339-4600
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Fax | 626-339-4099
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GRACE MIJIN KIM
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Credential | D.D.S
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Telephone | 626-339-4600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 58445
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License Number State | CA
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