Healthcare Provider Details

I. General information

NPI: 1912128877
Provider Name (Legal Business Name): JONATHAN GWAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CLINIC DR
NORWICH CT
06360
US

IV. Provider business mailing address

25 BROAD ST EXT APT B 315
GROTON CT
06340
US

V. Phone/Fax

Practice location:
  • Phone: 860-889-4044
  • Fax:
Mailing address:
  • Phone: 917-385-8182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9420
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: