Healthcare Provider Details

I. General information

NPI: 1316636087
Provider Name (Legal Business Name): WILLIAM KWAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MONROE ST
ENDICOTT NY
13760-5512
US

IV. Provider business mailing address

119 BRIARCLIFF DR
MORGANVILLE NJ
07751-2049
US

V. Phone/Fax

Practice location:
  • Phone: 607-953-4445
  • Fax:
Mailing address:
  • Phone: 732-570-8057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number065344-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: