Provider Demographics
NPI:1164618724
Name:KWON, CHANG HUN
Entity Type:Individual
Prefix:DR
First Name:CHANG HUN
Middle Name:
Last Name:KWON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:
Other - Last Name:KWON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:25920 IRIS AVE STE 14A
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-1658
Mailing Address - Country:US
Mailing Address - Phone:949-793-3391
Mailing Address - Fax:
Practice Address - Street 1:25920 IRIS AVE STE 14A
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92551-1658
Practice Address - Country:US
Practice Address - Phone:949-793-3391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA563621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice