Provider Demographics
NPI:1649689704
Name:KWON, GAE WON (DDS)
Entity type:Individual
Prefix:
First Name:GAE WON
Middle Name:
Last Name:KWON
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 1:13403 NEWCASTLE COMMONS DR APT 301
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98059-3220
Mailing Address - Country:US
Mailing Address - Phone:949-355-3676
Mailing Address - Fax:
Practice Address - Street 1:1901 CALLE DE NINOS
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3293
Practice Address - Country:US
Practice Address - Phone:575-526-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-03
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0400631223G0001X
NMDD54711223P0221X
WADE.612948501223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice