Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 50151 | CA |
NPI | 1134342025 |
---|---|
Provider Name | Luis Woong-Jin Kim |
First Address | Albany, CA 94707-2122 |
Second Address | Albany, CA 94707-2122 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2007 |
Last Update Date | 18/07/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
412170551 | TAX I.D. (01) | CA |