MEDICARE: GITAE KIM DENTAL GROUP 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	261QD0000X	Dental Clinic/Center	58750	CA

General Provider Information

NPI Number	:	1962919571
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GITAE KIM DENTAL GROUP INC

Provider Business Mailing Address
First Line	:	3054 W 8TH ST STE 106
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90005-1895
Country	:	US
Telephone Number	:	213-384-2864
Fax Number	:	213-384-2386

Provider Business Practice Location Address
First Line	:	3054 W 8TH ST STE 106
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90005-1895
Country	:	US
Telephone Number	:	213-384-2864
Fax Number	:	213-384-2386

Authorized Official
Title or Position	:	DENTIST AND OWNER
Name	:	DR. GITAE KIM
Credential	:	DDS
Telephone Number	:	213-384-2864

Provider Enumeration Date	:	01/04/2018
Last Update Date	:	01/04/2018

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