Provider Demographics
NPI:1023193448
Name:KIM, CHULHWAN J (DMD)
Entity Type:Individual
Prefix:
First Name:CHULHWAN
Middle Name:J
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 MOUNTAIN AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-2343
Mailing Address - Country:US
Mailing Address - Phone:860-242-1044
Mailing Address - Fax:
Practice Address - Street 1:11 MOUNTAIN AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2343
Practice Address - Country:US
Practice Address - Phone:860-242-1044
Practice Address - Fax:860-242-8568
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9483122300000X
MA22064122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist