MEDICARE: DR. HYUNG TACK KIM D.D.S

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	55714	CA

General Provider Information

NPI Number	:	1457554123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HYUNG TACK KIM D.D.S

Provider Business Mailing Address
First Line	:	1751 CHANTILLY LN
Second Line	:
City	:	FULLERTON
State	:	CA
Zip	:	92833-1289
Country	:	US
Telephone Number	:	310-893-9794
Fax Number	:

Provider Business Practice Location Address
First Line	:	2681 W OLYMPIC BLVD STE 220
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2883
Country	:	US
Telephone Number	:	213-251-8999
Fax Number	:	213-251-8909

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

Provider Enumeration Date	:	06/08/2007
Last Update Date	:	03/19/2020

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