Provider Demographics
NPI:1609941400
Name:NAM, JOHNNY KWAN (DDS)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:KWAN
Last Name:NAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9561 BRADDOCK RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-2539
Mailing Address - Country:US
Mailing Address - Phone:703-323-6500
Mailing Address - Fax:
Practice Address - Street 1:9561 BRADDOCK RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-2539
Practice Address - Country:US
Practice Address - Phone:703-323-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014107291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice