1952748295 NPI number — DR. CHRISTOPHER KIM, DDS, PA

Table of content: (NPI 1952748295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952748295 NPI number — DR. CHRISTOPHER KIM, DDS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. CHRISTOPHER KIM, DDS, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EAGLE MOUNTAIN DENTISTRY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952748295
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1609 OVERLOOK TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KELLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76262-9321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-750-5433
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8455 BOAT CLUB RD
Provider Second Line Business Practice Location Address:
SUITE 175
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76179-3632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-750-5433
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KIM
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
CHAEHO
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
817-750-5433

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  21561 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)