MEDICARE: DR. KYO SUNG KIM DDS, MS

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	48485	CA

General Provider Information

NPI Number	:	1881758894
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYO SUNG KIM DDS, MS

Provider Business Mailing Address
First Line	:	11247 WAREHAM CT
Second Line	:
City	:	LOMA LINDA
State	:	CA
Zip	:	92354-4875
Country	:	US
Telephone Number	:	909-799-9889
Fax Number	:	909-799-9889

Provider Business Practice Location Address
First Line	:	3700 WILSHIRE BLVD STE 780
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-3001
Country	:	US
Telephone Number	:	213-380-7900
Fax Number	:	213-380-7900

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

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	07/08/2007

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