Provider Demographics
NPI:1609364538
Name:KWON, SUSAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:KWON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:NOH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:NBHC MAYPORT
Mailing Address - Street 2:2104 MASSEY AVE
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:32228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10900 LOS ALAMITOS BLVD STE 133
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-5612
Practice Address - Country:US
Practice Address - Phone:562-596-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPENDING122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No122300000XDental ProvidersDentist