Healthcare Provider Details

I. General information

NPI: 1952615130
Provider Name (Legal Business Name): EUNEJENE KWAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAY KWAK

II. Dates (important events)

Enumeration Date: 07/30/2010
Last Update Date: 07/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4536 CHAMBLEE DUNWOODY RD SUITE 211
ATLANTA GA
30338-6200
US

IV. Provider business mailing address

4536 CHAMBLEE DUNWOODY RD SUITE 211
ATLANTA GA
30338-6200
US

V. Phone/Fax

Practice location:
  • Phone: 770-455-1238
  • Fax: 770-488-9550
Mailing address:
  • Phone: 770-455-1238
  • Fax: 770-488-9550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: