Provider Demographics
NPI:1538692314
Name:SAMUEL S. KWON,DMD-IV CENTER PC
Entity Type:Organization
Organization Name:SAMUEL S. KWON,DMD-IV CENTER PC
Other - Org Name:KWON PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:SALMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-714-7575
Mailing Address - Street 1:3590 BRASELTON HWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-1117
Mailing Address - Country:US
Mailing Address - Phone:678-714-7575
Mailing Address - Fax:678-714-7525
Practice Address - Street 1:3590 BRASELTON HWY BLDG B
Practice Address - Street 2:STE 100
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1117
Practice Address - Country:US
Practice Address - Phone:678-714-7575
Practice Address - Fax:678-714-7525
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAMUEL S. KWON DMD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-07
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA724916844CMedicaid