Provider Demographics
NPI:1023008174
Name:KWON, JAMES IKJAE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:IKJAE
Last Name:KWON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:IK-JAE
Other - Middle Name:
Other - Last Name:KWON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:177 W NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-3550
Mailing Address - Country:US
Mailing Address - Phone:847-991-0903
Mailing Address - Fax:847-991-0832
Practice Address - Street 1:177 W NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-3550
Practice Address - Country:US
Practice Address - Phone:847-991-0903
Practice Address - Fax:847-991-0832
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190263241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019026324Medicaid