Healthcare Provider Details

I. General information

NPI: 1316509367
Provider Name (Legal Business Name): GRACE KIMEUNHYE KWON DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GRACE MISUN KIM

II. Dates (important events)

Enumeration Date: 06/30/2019
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 PARK AVE
WORCESTER MA
01610-1025
US

IV. Provider business mailing address

3 COLD SPRING DR
GRAFTON MA
01519-1027
US

V. Phone/Fax

Practice location:
  • Phone: 508-798-6565
  • Fax:
Mailing address:
  • Phone: 404-488-3283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1858542
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN1858542
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: