Healthcare Provider Details

I. General information

NPI: 1982816542
Provider Name (Legal Business Name): HENRY SANG KWON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2836 W RIALTO AVE # A
RIALTO CA
92376-6743
US

IV. Provider business mailing address

1165 OVERLOOK RIDGE RD
DIAMOND BAR CA
91765-1133
US

V. Phone/Fax

Practice location:
  • Phone: 909-820-9454
  • Fax: 909-820-9482
Mailing address:
  • Phone: 213-675-6418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number47505
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: