Provider Demographics
NPI:1700045523
Name:KWONG, THOMAS (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:KWONG
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5907 OAKLAND DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1120
Mailing Address - Country:US
Mailing Address - Phone:269-327-4459
Mailing Address - Fax:
Practice Address - Street 1:5907 OAKLAND DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-1120
Practice Address - Country:US
Practice Address - Phone:269-327-4459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190276171223G0001X
MI2901020356122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice