Healthcare Provider Details

I. General information

NPI: 1760963904
Provider Name (Legal Business Name): SO DAM KWON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2018
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5404 PRESTON RD
FRISCO TX
75034-7471
US

IV. Provider business mailing address

7200 DALLAS PKWY APT 1725
PLANO TX
75024-5035
US

V. Phone/Fax

Practice location:
  • Phone: 972-963-9104
  • Fax:
Mailing address:
  • Phone: 707-853-6226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberNOTYET
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number36189
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: