MEDICARE: JAMES YOUNG KIM D.D.S 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	1223G0001X	General Practice Dentistry	34506	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	26-3123994	OTHER	CA	INTERNAL REVENUE SERVICE

General Provider Information

NPI Number	:	1710044771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES YOUNG KIM D.D.S INC.

Provider Business Mailing Address
First Line	:	15890 GALE AVE
Second Line	:
City	:	HACIENDA HEIGHTS
State	:	CA
Zip	:	91745-1601
Country	:	US
Telephone Number	:	626-333-0111
Fax Number	:	626-333-2400

Provider Business Practice Location Address
First Line	:	15890 GALE AVE
Second Line	:
City	:	HACIENDA HEIGHTS
State	:	CA
Zip	:	91745-1601
Country	:	US
Telephone Number	:	626-333-0111
Fax Number	:	626-333-2400

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

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	06/08/2010

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