MEDICARE: KENNY KIM 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	54955	CA

General Provider Information

NPI Number	:	1336352830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNY KIM DDS

Provider Business Mailing Address
First Line	:	20147 PIONEER BLVD
Second Line	:
City	:	LAKEWOOD
State	:	CA
Zip	:	90715-1051
Country	:	US
Telephone Number	:	562-924-0558
Fax Number	:

Provider Business Practice Location Address
First Line	:	20147 PIONEER BLVD
Second Line	:
City	:	LAKEWOOD
State	:	CA
Zip	:	90715-1051
Country	:	US
Telephone Number	:	562-924-0558
Fax Number	:

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

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	12/14/2017

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