Provider Demographics
NPI:1649795964
Name:KWON, GI TAE (DDS)
Entity type:Individual
Prefix:DR
First Name:GI TAE
Middle Name:
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 1:4003 MAPLE TREE LN
Mailing Address - Street 2:
Mailing Address - City:EAST LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06333-1671
Mailing Address - Country:US
Mailing Address - Phone:201-707-4661
Mailing Address - Fax:
Practice Address - Street 1:258 S FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-2641
Practice Address - Country:US
Practice Address - Phone:860-437-3462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT118561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice