Provider Demographics
NPI:1518453851
Name:JANG, YI KWON (DMD)
Entity Type:Individual
Prefix:DR
First Name:YI KWON
Middle Name:
Last Name:JANG
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 1:13945 MONO WAY
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-2823
Mailing Address - Country:US
Mailing Address - Phone:209-533-9630
Mailing Address - Fax:
Practice Address - Street 1:13945 MONO WAY
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-2823
Practice Address - Country:US
Practice Address - Phone:209-533-9630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1026861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice