MEDICARE: GP FAMILY DENTISTRY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	21422	TX

General Provider Information

NPI Number	:	1104257880
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GP FAMILY DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	PO BOX 543248
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75054-3248
Country	:	US
Telephone Number	:	972-262-1395
Fax Number	:	972-262-1397

Provider Business Practice Location Address
First Line	:	117 N BELT LINE RD
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75050-5800
Country	:	US
Telephone Number	:	972-262-1395
Fax Number	:	972-262-1397

Authorized Official
Title or Position	:	OWNER/ DENTIST
Name	:	SOO BIN KIM
Credential	:	DDS
Telephone Number	:	404-354-6787

Provider Enumeration Date	:	12/06/2013
Last Update Date	:	12/06/2013

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