MEDICARE: SEAN KIM, DDS, 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	261QD0000X	Dental Clinic/Center	102689	CA

General Provider Information

NPI Number	:	1306323035
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEAN KIM, DDS, INC.

Provider Business Mailing Address
First Line	:	936 CRENSHAW BLVD STE 101
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-1948
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1213 N LAKE AVE
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91104-3768
Country	:	US
Telephone Number	:	626-584-1800
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. SEAN SUNYOTO
Credential	:	DDS
Telephone Number	:	626-510-2606

Provider Enumeration Date	:	07/25/2018
Last Update Date	:	07/25/2018

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