Provider Demographics
NPI:1437503356
Name:CHARLES C. KIM, D.D.S., INC.
Entity Type:Organization
Organization Name:CHARLES C. KIM, D.D.S., INC.
Other - Org Name:WATERFORD FAMILY DENTIST, DENTAL PRACTICE OF DR. CHARLES C. KIM, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:CHANWOONG
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-874-2337
Mailing Address - Street 1:12142 YOSEMITE BLVD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CA
Mailing Address - Zip Code:95386-9163
Mailing Address - Country:US
Mailing Address - Phone:209-874-2337
Mailing Address - Fax:209-874-9822
Practice Address - Street 1:12142 YOSEMITE BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CA
Practice Address - Zip Code:95386-9163
Practice Address - Country:US
Practice Address - Phone:209-874-2337
Practice Address - Fax:209-874-9822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA611121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty