Provider Demographics
NPI:1871014902
Name:KIM, CHARLIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLIE
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CAMP HUMPHREYS
Mailing Address - Street 2:CARIUS DENTAL CLINIC BLDG 3020
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96271
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CAMP HUMPHREYS
Practice Address - Street 2:CARIUS DENTAL CLINIC BLDG 3020
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96271
Practice Address - Country:US
Practice Address - Phone:050-737-3368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101473122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist