Provider Demographics
NPI:1689049330
Name:SAMUEL S KWON - LOGANVILLE DMD PC
Entity Type:Organization
Organization Name:SAMUEL S KWON - LOGANVILLE DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:KWON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
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 1:2101 BAKER CARTER DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052
Practice Address - Country:US
Practice Address - Phone:678-714-7575
Practice Address - Fax:678-714-7525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126871223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty