MEDICARE: KENNETH H KIM,DDS, A PROFESSIONAL CORP.

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	53892	CA

General Provider Information

NPI Number	:	1184829830
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNETH H KIM,DDS, A PROFESSIONAL CORP.

Provider Business Mailing Address
First Line	:	2723 N BRISTOL ST
Second Line	:	SUITE #D-2
City	:	SANTA ANA
State	:	CA
Zip	:	92706-1419
Country	:	US
Telephone Number	:	714-550-0006
Fax Number	:	714-550-0007

Provider Business Practice Location Address
First Line	:	2723 N BRISTOL ST
Second Line	:	SUITE #D-2
City	:	SANTA ANA
State	:	CA
Zip	:	92706-1419
Country	:	US
Telephone Number	:	714-550-0006
Fax Number	:	714-550-0007

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KENNETH HYON MO KIM
Credential	:	DDS
Telephone Number	:	714-550-0006

Provider Enumeration Date	:	06/20/2007
Last Update Date	:	08/10/2007

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