Provider Demographics
NPI:1477113850
Name:KWON, PIL JAE (DMD)
Entity Type:Individual
Prefix:
First Name:PIL
Middle Name:JAE
Last Name:KWON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 KNEELAND ST APT 512
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-2436
Mailing Address - Country:US
Mailing Address - Phone:404-422-6726
Mailing Address - Fax:
Practice Address - Street 1:725 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476
Practice Address - Country:US
Practice Address - Phone:781-489-3315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858402122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist