MEDICARE: KIM HENDERSON KIDS DENTISTRY PC

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

General Provider Information

NPI Number	:	1568153161
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIM HENDERSON KIDS DENTISTRY PC

Provider Business Mailing Address
First Line	:	PO BOX 920050
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75392-0050
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	382 W LAKE MEAD PKWY STE 130
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89015-7292
Country	:	US
Telephone Number	:	703-558-8543
Fax Number	:	702-673-1119

Authorized Official
Title or Position	:	OWNER
Name	:	KYUNG M KING
Credential	:	DDS
Telephone Number	:	702-558-8543

Provider Enumeration Date	:	05/16/2023
Last Update Date	:	05/16/2023

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