Provider Demographics
NPI:1750954608
Name:KWON, GRACE E (DMD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:E
Last Name:KWON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3590 BRASELTON HWY
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-1117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3590 BRASELTON HWY STE 201
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1120
Practice Address - Country:US
Practice Address - Phone:678-714-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1223291223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice