Healthcare Provider Details

I. General information

NPI: 1255726170
Provider Name (Legal Business Name): DR. HYUK SANG KWON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 W JUNEAU AVE APT 122
MILWAUKEE WI
53233-1450
US

IV. Provider business mailing address

1621 W WELLS ST APT #409
MILWAUKEE WI
53233-3204
US

V. Phone/Fax

Practice location:
  • Phone: 402-517-2220
  • Fax:
Mailing address:
  • Phone: 414-377-2371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6001028
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: