Provider Demographics
NPI:1952748295
Name:DR. CHRISTOPHER KIM, DDS, PA
Entity Type:Organization
Organization Name:DR. CHRISTOPHER KIM, DDS, PA
Other - Org Name:EAGLE MOUNTAIN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:CHAEHO
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-750-5433
Mailing Address - Street 1:1609 OVERLOOK TER
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76262-9321
Mailing Address - Country:US
Mailing Address - Phone:817-750-5433
Mailing Address - Fax:
Practice Address - Street 1:8455 BOAT CLUB RD
Practice Address - Street 2:SUITE 175
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-3632
Practice Address - Country:US
Practice Address - Phone:817-750-5433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21561261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental