MEDICARE: WILLIAM DAE WON KIM D.D.S. A DENTAL CORPORATION

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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639963473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLIAM DAE WON KIM D.D.S. A DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	2485 QUEENSBERRY RD
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91104-3440
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	906 N VERMONT AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-3519
Country	:	US
Telephone Number	:	323-522-3382
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. WILLIAM DAE WON KIM
Credential	:	DDS
Telephone Number	:	213-270-5432

Provider Enumeration Date	:	04/07/2025
Last Update Date	:	04/07/2025

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