Healthcare Provider Details

I. General information

NPI: 1295426963
Provider Name (Legal Business Name): MAGICLAND DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 PARK ST STE C
HARTFORD CT
06106-2232
US

IV. Provider business mailing address

1011 MAIN ST
EAST HARTFORD CT
06108-2294
US

V. Phone/Fax

Practice location:
  • Phone: 860-528-3350
  • Fax:
Mailing address:
  • Phone: 212-786-2187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. YOON JOONG ALLAN KWON
Title or Position: MEMBER
Credential: DDS
Phone: 212-786-2187