Provider Demographics
NPI:1457641136
Name:EVERGREEN DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:EVERGREEN DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHIA HUI
Authorized Official - Middle Name:JENNY
Authorized Official - Last Name:KWON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-453-4055
Mailing Address - Street 1:34 EVERGREEN WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-6976
Mailing Address - Country:US
Mailing Address - Phone:917-453-4055
Mailing Address - Fax:
Practice Address - Street 1:34 EVERGREEN WAY
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-6976
Practice Address - Country:US
Practice Address - Phone:917-453-4055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0101101223G0001X
CT0102411223G0001X
CT0100041223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty