Provider Demographics
NPI:1427467331
Name:KIM, CHARLES (DDS)
Entity type:Individual
Prefix:DR
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 1:18605 CECELIA WAY
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-6136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18605 CECELIA WAY
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-6136
Practice Address - Country:US
Practice Address - Phone:562-484-1228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63819122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist