Provider Demographics
NPI:1912518531
Name:SAMUEL S KWON - ATHENS DMD PC
Entity Type:Organization
Organization Name:SAMUEL S KWON - ATHENS DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-714-7575
Mailing Address - Street 1:1795 RESURGENCE DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677
Mailing Address - Country:US
Mailing Address - Phone:678-714-7575
Mailing Address - Fax:678-804-9434
Practice Address - Street 1:1795 RESURGENCE DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677
Practice Address - Country:US
Practice Address - Phone:678-714-7575
Practice Address - Fax:678-804-9434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty