Healthcare Provider Details

I. General information

NPI: 1669897807
Provider Name (Legal Business Name): KWONG ORTHODONTICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6121 S WESTNEDGE AVE
PORTAGE MI
49002-2882
US

IV. Provider business mailing address

6121 S WESTNEDGE AVE
PORTAGE MI
49002-2882
US

V. Phone/Fax

Practice location:
  • Phone: 269-366-0882
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901020356
License Number StateMI

VIII. Authorized Official

Name: DR. THOMAS KWONG
Title or Position: OWNER
Credential: DDS, MS
Phone: 269-366-0882