MEDICARE: KELLY S JIN DMD

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	1223G0001X	General Practice Dentistry	45360	CA

General Provider Information

NPI Number	:	1477109353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY S JIN DMD

Provider Business Mailing Address
First Line	:	6612 SILVERSPUR LN
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92648-1503
Country	:	US
Telephone Number	:	714-342-0121
Fax Number	:

Provider Business Practice Location Address
First Line	:	6612 SILVERSPUR LN
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92648-1503
Country	:	US
Telephone Number	:	714-342-0121
Fax Number	:

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

Provider Enumeration Date	:	08/15/2019
Last Update Date	:	08/15/2019

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