Active NPI
Dongyeon Kim
- Pediatric Dentistry
- Union, MO
National Provider Identifier
1295224418
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- License
- 2023005564
- Practice address
- 1780 Old Highway 50 E
Union, MO 63084-3219 - Phone
- (639) 695-6055
- NPI assigned
- May 2, 2018
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 4
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | DDS107522 | CA | |
| Pediatric Dentistry | 1223P0221X | DDS107522 | CA | |
| Student in an Organized Health Care Education/Training Program | 390200000X | |||
| Pediatric Dentistry | 1223P0221X | 2023005564 | MO | Primary |
Addresses
Primary practice location
1780 Old Highway 50 E
Union, MO 63084-3219
Mailing address
2290 Daniels St
Manteca, CA 95337-6706
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in NY
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20190111002679 | NY | Order and Referring Only - Dentist | 4981940988 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DDS107522 | CA | MD | Pediatric Dentist |
| 2023005564 | MO | MD | Pediatric Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1525219200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1681603200000",
"number": "1295224418",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2290 DANIELS ST",
"city": "MANTECA",
"state": "CA",
"postal_code": "953376706"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1780 OLD HIGHWAY 50 E",
"city": "UNION",
"state": "MO",
"postal_code": "630843219",
"telephone_number": "639-695-6055"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KIM",
"first_name": "DONGYEON",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2018-05-02",
"last_updated": "2023-04-16",
"certification_date": "2023-04-16",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "CA",
"license": "DDS107522",
"primary": false
},
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "CA",
"license": "DDS107522",
"primary": false
},
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": null,
"license": null,
"primary": false
},
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "MO",
"license": "2023005564",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Union, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 16, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.