Provider Demographics
NPI:1235685967
Name:KIM, MICHAEL CHARLES (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHARLES
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:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:OR
Mailing Address - Zip Code:97113-0568
Mailing Address - Country:US
Mailing Address - Phone:503-352-8642
Mailing Address - Fax:503-335-2865
Practice Address - Street 1:730 SE OAK ST
Practice Address - Street 2:SUITE A & B
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4245
Practice Address - Country:US
Practice Address - Phone:503-352-2354
Practice Address - Fax:503-352-2363
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10518122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist