Provider Demographics
NPI:1093198160
Name:KWON, MI AE (DMD)
Entity Type:Individual
Prefix:MS
First Name:MI AE
Middle Name:
Last Name:KWON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3739 W. NEPTUNE ST.
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629
Mailing Address - Country:US
Mailing Address - Phone:813-856-1292
Mailing Address - Fax:
Practice Address - Street 1:3739 W. NEPTUNE ST.
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629
Practice Address - Country:US
Practice Address - Phone:813-856-1292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN215191223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program