Provider Demographics
NPI:1578273082
Name:KWAK, MIN GYU (DDS, PHD)
Entity Type:Individual
Prefix:DR
First Name:MIN GYU
Middle Name:
Last Name:KWAK
Suffix:
Gender:M
Credentials:DDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BARSTOW RD APT 5A
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-2202
Mailing Address - Country:US
Mailing Address - Phone:631-332-6643
Mailing Address - Fax:
Practice Address - Street 1:21 BARSTOW RD APT 5A
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2202
Practice Address - Country:US
Practice Address - Phone:631-332-6643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0629151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY062915OtherNEW YORK STATE DENTAL LICENSE