Healthcare Provider Details

I. General information

NPI: 1407857295
Provider Name (Legal Business Name): CHARLES J RIM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHARLIE JI RIM

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 05/31/2024
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 S MOODY AVE
PORTLAND OR
97201-5042
US

IV. Provider business mailing address

17661 WOODHURST PL
LAKE OSWEGO OR
97034-4010
US

V. Phone/Fax

Practice location:
  • Phone: 503-346-4710
  • Fax:
Mailing address:
  • Phone: 503-799-5698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number46521
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD9033
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: