1558683649 NPI number — HENRY S. KWON, D.D.S. INC.

Table of content: (NPI 1558683649)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558683649 NPI number — HENRY S. KWON, D.D.S. INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HENRY S. KWON, D.D.S. INC.
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:
1558683649
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2836 W RIALTO AVE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIALTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92376-6816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-820-9454
Provider Business Mailing Address Fax Number:
909-820-9482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2836 W RIALTO AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIALTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92376-6816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-820-9454
Provider Business Practice Location Address Fax Number:
909-820-9482
Provider Enumeration Date:
02/17/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KWON
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PROVIDER/PRESIDENT
Authorized Official Telephone Number:
909-820-9454

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D47505 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: B4750501 . This is a "DENTI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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