Provider Demographics
NPI:1033583349
Name:JOO, KYUNG WON (DDS)
Entity Type:Individual
Prefix:
First Name:KYUNG WON
Middle Name:
Last Name:JOO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 ENVERO WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-6960
Mailing Address - Country:US
Mailing Address - Phone:916-216-6230
Mailing Address - Fax:
Practice Address - Street 1:3512 ENVERO WAY
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-6960
Practice Address - Country:US
Practice Address - Phone:916-216-6230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA652121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice