Healthcare Provider Details

I. General information

NPI: 1104125855
Provider Name (Legal Business Name): SUNSET DENTAL PROFESSIONAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1042 W WEST COVINA PKWY
WEST COVINA CA
91790-2810
US

IV. Provider business mailing address

1042 W WEST COVINA PKWY
WEST COVINA CA
91790-2810
US

V. Phone/Fax

Practice location:
  • Phone: 626-960-2766
  • Fax: 626-962-8216
Mailing address:
  • Phone: 626-960-2766
  • Fax: 626-962-8216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number52627
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number54659
License Number StateCA

VIII. Authorized Official

Name: DR. ANDREW WOOSUNG KWON
Title or Position: DENTIST
Credential: DDS
Phone: 626-960-2766