MEDICARE: MS. KIMCHI T DO DDS

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	122300000X	Dentist	46781	CA

General Provider Information

NPI Number	:	1194831255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMCHI T DO DDS

Provider Business Mailing Address
First Line	:	4202 N PECK RD
Second Line	:
City	:	EL MONTE
State	:	CA
Zip	:	91732
Country	:	US
Telephone Number	:	626-401-0012
Fax Number	:

Provider Business Practice Location Address
First Line	:	4202 N PECK RD
Second Line	:
City	:	EL MONTE
State	:	CA
Zip	:	91732
Country	:	US
Telephone Number	:	626-401-0012
Fax Number	:	626-401-1009

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/08/2007

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