Healthcare Provider Details

I. General information

NPI: 1114370079
Provider Name (Legal Business Name): KWON & JABBOUR DENTAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 LA CASA VIA SUITE 102
WALNUT CREEK CA
94598-3013
US

IV. Provider business mailing address

108 LA CASA VIA SUITE 102
WALNUT CREEK CA
94598-3013
US

V. Phone/Fax

Practice location:
  • Phone: 925-930-8465
  • Fax: 925-930-9955
Mailing address:
  • Phone: 925-930-8465
  • Fax: 925-930-9955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number46279
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number46074
License Number StateCA

VIII. Authorized Official

Name: DR. HANI JABBOUR
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 925-930-8465