Provider Demographics
NPI:1740835230
Name:KWON, GLORIA HA-YOUNG (DDS)
Entity type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:HA-YOUNG
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 1:7461 BLACKMON RD APT 4515
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-8407
Mailing Address - Country:US
Mailing Address - Phone:734-277-8718
Mailing Address - Fax:
Practice Address - Street 1:7101 HOFF ST
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-5645
Practice Address - Country:US
Practice Address - Phone:706-544-4795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901023212122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist