=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972044337
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | O.J KWON DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2017
-----------------------------------------------------
Last Update Date | 03/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9675 MONTE VISTA AVE SUITE G
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91763-2233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-576-7175
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9675 MONTE VISTA AVE SUITE G
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91763-2233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-576-7175
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. OH JAE KWON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 909-576-7175
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 46484
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------