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General NPI Number Information
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NPI Number | 1104125855
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Entity Type | Organization
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Legal Business Name | SUNSET DENTAL PROFESSIONAL
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Dates
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Enumeration Date | 03/21/2011
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Last Update Date | 03/21/2011
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Provider Practice Location Address
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Address Line | 1042 W WEST COVINA PKWY
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City | WEST COVINA
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State | CA
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Zip | 91790-2810
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Country | US
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Telephone | 626-960-2766
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Fax | 626-962-8216
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Provider Business Mailing Address
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Address Line | 1042 W WEST COVINA PKWY
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City | WEST COVINA
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State | CA
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Zip | 91790-2810
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Country | US
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Telephone | 626-960-2766
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Fax | 626-962-8216
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Authorized Official
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Title or Position | DENTIST
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Name | DR. ANDREW WOOSUNG KWON
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Credential | DDS
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Telephone | 626-960-2766
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 54659
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 52627
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License Number State | CA
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