Healthcare Provider Details

I. General information

NPI: 1912269945
Provider Name (Legal Business Name): KENNIE KWOK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 4TH AVE SUITE 303
SAN DIEGO CA
92103-2116
US

IV. Provider business mailing address

4060 4TH AVE SUITE 303
SAN DIEGO CA
92103-2116
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-0905
  • Fax:
Mailing address:
  • Phone: 619-543-0905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number65162
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: