Provider Demographics
NPI:1790030633
Name:HWANG, KELLY J (DDS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:HWANG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-4118
Mailing Address - Country:US
Mailing Address - Phone:951-245-5003
Mailing Address - Fax:
Practice Address - Street 1:141 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4118
Practice Address - Country:US
Practice Address - Phone:951-245-5003
Practice Address - Fax:951-471-0637
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28225122300000X
CA61930122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist