Provider Demographics
NPI:1881021434
Name:KWON DDS PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:KWON DDS PROFESSIONAL CORPORATION
Other - Org Name:MEAD VALLEY COMMUNITY DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OH JAE
Authorized Official - Middle Name:
Authorized Official - Last Name:KWON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-322-4058
Mailing Address - Street 1:21091 RIDER ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-8878
Mailing Address - Country:US
Mailing Address - Phone:951-322-4058
Mailing Address - Fax:
Practice Address - Street 1:21091 RIDER ST
Practice Address - Street 2:SUITE 203
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-8878
Practice Address - Country:US
Practice Address - Phone:951-322-4058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KWON DDS PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-27
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46484122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty