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General NPI Number Information
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NPI Number | 1174212740
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Entity Type | Organization
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Legal Business Name | JAE HEE KWAK DMD INC
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Dates
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Enumeration Date | 05/01/2023
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Last Update Date | 05/01/2023
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Provider Practice Location Address
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Address Line | 1631 EDINGER AVE STE 105
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City | TUSTIN
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State | CA
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Zip | 92780-6537
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Country | US
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Telephone | 714-717-3757
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Fax |
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Provider Business Mailing Address
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Address Line | 1631 EDINGER AVE STE 105
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City | TUSTIN
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State | CA
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Zip | 92780-6537
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Country | US
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Telephone | 714-717-3757
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JAE KWAK
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Credential | DMD
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Telephone | 469-449-3162
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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