Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223G0001X | General Practice | 00000000 | WA |
N | 213EG0000X | General Practice | 00000000 | WA |
N | 1223G0001X | General Practice | D10635 | OR |
N | 213EG0000X | General Practice | D10635 | OR |
Y | 1223P0221X | Pediatric Dentist | 104759 | CA |
NPI | 1033562939 |
---|---|
Provider Name | Dr. Scarlet Kim |
First Address | Walnut, CA 91789-3506 |
Second Address | Mission Viejo, CA 92691-4534 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/07/2016 |
Last Update Date | 24/11/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PENDING | (05) | WA |