Provider Demographics
NPI:1053473736
Name:KWON, JIN SANG (DDS)
Entity Type:Individual
Prefix:
First Name:JIN SANG
Middle Name:
Last Name:KWON
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 1:1822 EMPRESS LN
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-8707
Mailing Address - Country:US
Mailing Address - Phone:209-485-6638
Mailing Address - Fax:
Practice Address - Street 1:2045 W BRIGGSMORE AVE
Practice Address - Street 2:SUITE E
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-3767
Practice Address - Country:US
Practice Address - Phone:209-527-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA536161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice