Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | D29722 | CA |
NPI | 1104962224 |
---|---|
Provider Name | Dr. Kim Jon Dipasquale |
First Address | Anaheim Hills, CA 92807 |
Second Address | Anaheim Hills, CA 92807 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T70460 | (02) | CA |