Provider Demographics
NPI:1417478223
Name:KWAK, JENISE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENISE
Middle Name:
Last Name:KWAK
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 1:2800 S INTERSTATE 35 STE 500
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78681-8098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2800 S INTERSTATE 35 STE 500
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78681-8098
Practice Address - Country:US
Practice Address - Phone:512-726-0440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX350141223G0001X
MADN18576711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice