MEDICARE: LAKEWOOD OMF SURGERY, INC.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	A87499	CA

General Provider Information

NPI Number	:	1285927350
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKEWOOD OMF SURGERY, INC.

Provider Business Mailing Address
First Line	:	4448 E VILLAGE RD
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-1540
Country	:	US
Telephone Number	:	562-421-9369
Fax Number	:	562-420-8950

Provider Business Practice Location Address
First Line	:	4448 E VILLAGE RD
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-1540
Country	:	US
Telephone Number	:	562-421-9369
Fax Number	:	562-420-8950

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DAVID HWAN KIM
Credential	:	M.D., D.D.S.
Telephone Number	:	562-421-9369

Provider Enumeration Date	:	05/24/2011
Last Update Date	:	05/24/2011

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