MEDICARE: KIM, KIM, NGUYEN DDS DENTAL CORPORATION

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	1223P0221X	Pediatric Dentistry	B42748	CA

General Provider Information

NPI Number	:	1124119797
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIM, KIM, NGUYEN DDS DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	39755 MURRIETA HOT SPRINGS RD STE E110
Second Line	:
City	:	MURRIETA
State	:	CA
Zip	:	92563-9114
Country	:	US
Telephone Number	:	951-461-6622
Fax Number	:	951-461-6790

Provider Business Practice Location Address
First Line	:	39755 MURRIETA HOT SPRINGS RD STE E110
Second Line	:
City	:	MURRIETA
State	:	CA
Zip	:	92563-9114
Country	:	US
Telephone Number	:	951-461-6622
Fax Number	:	951-461-6790

Authorized Official
Title or Position	:	OWNER
Name	:	DR. QUY N KIM
Credential	:
Telephone Number	:	951-461-6622

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	08/12/2009

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