Healthcare Provider Details

I. General information

NPI: 1952744005
Provider Name (Legal Business Name): JASON KWAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 12/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 PARK AVE SUITE #1
PLAINFIELD NJ
07060-3026
US

IV. Provider business mailing address

1024 PARK AVE SUITE #1
PLAINFIELD NJ
07060-3026
US

V. Phone/Fax

Practice location:
  • Phone: 908-668-5888
  • Fax:
Mailing address:
  • Phone: 908-668-5888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02563200
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0538558
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: