Provider Demographics
NPI:1083184790
Name:J.B. GWAK, DDS, PLLC
Entity Type:Organization
Organization Name:J.B. GWAK, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JI WON
Authorized Official - Middle Name:
Authorized Official - Last Name:GWAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-890-6457
Mailing Address - Street 1:306 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-2526
Mailing Address - Country:US
Mailing Address - Phone:310-890-6457
Mailing Address - Fax:360-568-4170
Practice Address - Street 1:306 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-2526
Practice Address - Country:US
Practice Address - Phone:310-890-6457
Practice Address - Fax:360-568-4170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA604312870OtherUBI