Provider Demographics
NPI:1023689759
Name:KIM, CHARLES (DDS)
Entity type:Individual
Prefix:
First Name:CHARLES
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 1:8511 S ROSE TERRACE LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-1173
Mailing Address - Country:US
Mailing Address - Phone:832-260-3936
Mailing Address - Fax:
Practice Address - Street 1:1401 S JEFFERSON AVE STE 4
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-5647
Practice Address - Country:US
Practice Address - Phone:903-572-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-03
Last Update Date:2021-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX373641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice