Provider Demographics
NPI:1184950669
Name:KWON, THOMAS SAN-YEOP (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:SAN-YEOP
Last Name:KWON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 KENMORE AVE,
Mailing Address - Street 2:SUITE 122
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304
Mailing Address - Country:US
Mailing Address - Phone:703-751-1112
Mailing Address - Fax:703-370-8875
Practice Address - Street 1:4701 KENMORE AVE,
Practice Address - Street 2:SUITE 122
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304
Practice Address - Country:US
Practice Address - Phone:703-751-1112
Practice Address - Fax:703-370-8875
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401008655122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist