Healthcare Provider Details

I. General information

NPI: 1033622246
Provider Name (Legal Business Name): MAGICLAND PEDIATRIC DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 WOLCOTT ST
WATERBURY CT
06705-1318
US

IV. Provider business mailing address

1011 MAIN ST
EAST HARTFORD CT
06108-2294
US

V. Phone/Fax

Practice location:
  • Phone: 860-282-0630
  • Fax:
Mailing address:
  • Phone:
  • 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. CHIA HUI JENNY KWON
Title or Position: MEMBER
Credential: DDS
Phone: 917-453-4055