Healthcare Provider Details

I. General information

NPI: 1003293077
Provider Name (Legal Business Name): CHRIS S KIM DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 JOHN MADDOX DR NW
ROME GA
30165-1413
US

IV. Provider business mailing address

21 JOHN MADDOX DR NW
ROME GA
30165-1413
US

V. Phone/Fax

Practice location:
  • Phone: 858-740-0706
  • Fax:
Mailing address:
  • Phone: 858-740-0706
  • Fax: 706-290-9577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD.007382-C
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number38247
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN015106
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7115
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number11132
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: