MEDICARE: DR. SOO YEON KIM DDS

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	105375	CA

General Provider Information

NPI Number	:	1821601121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SOO YEON KIM DDS

Provider Business Mailing Address
First Line	:	4514 PHILADELPHIA ST STE A
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-2240
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4514 PHILADELPHIA ST STE A
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-2240
Country	:	US
Telephone Number	:	909-443-2618
Fax Number	:

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

Provider Enumeration Date	:	08/26/2020
Last Update Date	:	12/12/2023

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