MEDICARE: JIN Y. KIM DDS, INC.

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	1223P0700X	Prosthodontics

General Provider Information

NPI Number	:	1639710973
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JIN Y. KIM DDS, INC.

Provider Business Mailing Address
First Line	:	9681 GARDEN GROVE BLVD STE 104
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92844-1548
Country	:	US
Telephone Number	:	714-539-8275
Fax Number	:	714-539-8284

Provider Business Practice Location Address
First Line	:	9681 GARDEN GROVE BLVD STE 104
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92844-1548
Country	:	US
Telephone Number	:	714-539-8275
Fax Number	:	714-539-8284

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JIN YOUNG KIM
Credential	:	D.D.S.
Telephone Number	:	323-445-6144

Provider Enumeration Date	:	10/07/2019
Last Update Date	:	10/07/2019

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