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General NPI Number Information
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NPI Number | 1578273082
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Entity Type | Individual
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Provider Name | MIN GYU KWAK DDS, PHD
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Gender | Male
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Dates
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Enumeration Date | 11/28/2022
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Last Update Date | 02/12/2026
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Provider Practice Location Address
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Address Line | 1895 BRENTWOOD RD
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City | BRENTWOOD
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State | NY
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Zip | 11717
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Country | US
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Telephone | 631-388-7717
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Fax | 631-388-7797
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Provider Business Mailing Address
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Address Line | 21 BARSTOW RD APT 5A
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City | GREAT NECK
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State | NY
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Zip | 11021-2202
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Country | US
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Telephone | 631-388-7717
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Fax | 631-388-7797
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 062915
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License Number State | NY
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