Healthcare Provider Details

I. General information

NPI: 1851666903
Provider Name (Legal Business Name): KWON DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 SE 223RD AVE STE 260
GRESHAM OR
97030-2580
US

IV. Provider business mailing address

1201 SE 223RD AVE STE 260
GRESHAM OR
97030-2580
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-2828
  • Fax: 503-618-9874
Mailing address:
  • Phone: 503-661-2828
  • Fax: 503-618-9874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateOR

VIII. Authorized Official

Name: DR. ROBIN KWON
Title or Position: DENTIST / OWNER
Credential: D.D.S.
Phone: 503-661-2828