Healthcare Provider Details

I. General information

NPI: 1346437753
Provider Name (Legal Business Name): KENNETH ANDREW TJON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2007
Last Update Date: 09/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27221 LA PAZ RD STE G
LAGUNA NIGUEL CA
92677-3630
US

IV. Provider business mailing address

27221 LA PAZ RD STE G
LAGUNA NIGUEL CA
92677-3630
US

V. Phone/Fax

Practice location:
  • Phone: 949-831-1402
  • Fax: 949-831-1872
Mailing address:
  • Phone: 949-831-1402
  • Fax: 949-831-1872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number41875
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: