1538692314 NPI number — SAMUEL S. KWON,DMD-IV CENTER PC

Table of content: (NPI 1538692314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538692314 NPI number — SAMUEL S. KWON,DMD-IV CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAMUEL S. KWON,DMD-IV CENTER PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538692314
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3590 BRASELTON HWY
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
DACULA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30019-1117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-714-7575
Provider Business Mailing Address Fax Number:
678-714-7525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3590 BRASELTON HWY BLDG B
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
DACULA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30019-1117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-714-7575
Provider Business Practice Location Address Fax Number:
678-714-7525
Provider Enumeration Date:
04/07/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SALMON
Authorized Official First Name:
RENEE
Authorized Official Middle Name:
Authorized Official Title or Position:
FINANCIAL MANAGER
Authorized Official Telephone Number:
678-714-7575

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 724916844C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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