Basic Information
| Provider Information | |||||||||
| NPI: | 1063546893 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | BUM | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 790 | ||||||||
| Address2: | 650 ZEDIKER AVE. | ||||||||
| City: | PARLIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936480790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596466618 | ||||||||
| FaxNumber: | 5596466614 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 BARBOZA ST | ||||||||
| Address2: | |||||||||
| City: | MENDOTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936401901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596555000 | ||||||||
| FaxNumber: | 5596556817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 50762 | CA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 50762 | 01 | CA | CALIFORNIA DENTAL LIC# | OTHER |