Healthcare Provider Details

I. General information

NPI: 1366918757
Provider Name (Legal Business Name): JUSTIN J KWON DDS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 11/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 NICKEL ST STE 500
BROOMFIELD CO
80020-2129
US

IV. Provider business mailing address

290 NICKEL ST STE 500
BROOMFIELD CO
80020-2129
US

V. Phone/Fax

Practice location:
  • Phone: 303-469-5301
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN KWON
Title or Position: OWNER
Credential: DDS
Phone: 303-469-5301