Provider Demographics
NPI:1477113850
Name:KWON, PIL JAE (DMD)
Entity type:Individual
Prefix:
First Name:PIL
Middle Name:JAE
Last Name:KWON
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 1:99 KNEELAND ST APT 512
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-2436
Mailing Address - Country:US
Mailing Address - Phone:404-422-6726
Mailing Address - Fax:
Practice Address - Street 1:771 OLD NORCROSS RD STE 125
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4978
Practice Address - Country:US
Practice Address - Phone:678-985-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2024-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1222891223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics