Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 58517 | CA |
N | 1223S0112X | Oral and Maxillofacial Surgeon | 58517 | CA |
Y | 1223S0112X | Oral and Maxillofacial Surgeon | S2-141C | NV |
N | 204E00000X | Oral & Maxillofacial Surgeon | 127414 | CA |
NPI | 1588896740 |
---|---|
Provider Name | James Kim |
First Address | Las Vegas, NV 89106-4043 |
Second Address | Las Vegas, NV 89117-9189 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/08/2009 |
Last Update Date | 15/06/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1588896740 | (05) | NV |