MEDICARE: CHERRYSTONE DENTAL, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	28520	TX
2	1223G0001X	General Practice Dentistry	28519	TX

General Provider Information

NPI Number	:	1851710339
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHERRYSTONE DENTAL, PLLC

Provider Business Mailing Address
First Line	:	6380 LOUETTA RD
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77379-7589
Country	:	US
Telephone Number	:	281-288-1500
Fax Number	:

Provider Business Practice Location Address
First Line	:	6380 LOUETTA RD
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77379-7589
Country	:	US
Telephone Number	:	281-288-1500
Fax Number	:

Authorized Official
Title or Position	:	OWNER DOCTOR
Name	:	DR. CHRISTOPHER KIM
Credential	:	DDS
Telephone Number	:	213-703-0104

Provider Enumeration Date	:	04/10/2014
Last Update Date	:	09/04/2014

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