Healthcare Provider Details

I. General information

NPI: 1225690670
Provider Name (Legal Business Name): JIN WUNG HWANG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2019
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 SAMPSON ST
GREAT LAKES IL
60088-2942
US

IV. Provider business mailing address

2410 SAMPSON ST
GREAT LAKES IL
60088-2942
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-2469
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS042301
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: