Provider Demographics
NPI:1013171396
Name:KO, HYUNG KWON (DMD)
Entity Type:Individual
Prefix:MR
First Name:HYUNG
Middle Name:KWON
Last Name:KO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 41ST ST APT 613
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5665
Mailing Address - Country:US
Mailing Address - Phone:510-409-4603
Mailing Address - Fax:
Practice Address - Street 1:225 41ST ST APT 613
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5665
Practice Address - Country:US
Practice Address - Phone:510-409-4603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037564122300000X
CA615381223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics