MEDICARE: DR. BRYAN BUMSOO KIM D.M.D.

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	32333	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	260891	OTHER	CA	UNITED CONCORDIA
2	B32333-01	OTHER	CA	DELTA HEALTHY FAMILY

General Provider Information

NPI Number	:	1417014655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRYAN BUMSOO KIM D.M.D.

Provider Business Mailing Address
First Line	:	3030 W. 8TH ST.
Second Line	:	#305
City	:	LOS ANGELES
State	:	CA
Zip	:	90005
Country	:	US
Telephone Number	:	213-389-0937
Fax Number	:	213-389-1937

Provider Business Practice Location Address
First Line	:	3030 W 8TH ST
Second Line	:	#305
City	:	LOS ANGELES
State	:	CA
Zip	:	90005-1812
Country	:	US
Telephone Number	:	213-389-0937
Fax Number	:	213-389-1937

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

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/08/2007

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