MEDICARE: DR. MIN JUNG KWON D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry		IL

General Provider Information

NPI Number	:	1609095678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MIN JUNG KWON D.D.S.

Provider Business Mailing Address
First Line	:	214 WASHINGTON ST
Second Line	:
City	:	INGLESIDE
State	:	IL
Zip	:	60041-9208
Country	:	US
Telephone Number	:	847-587-3020
Fax Number	:	847-587-1598

Provider Business Practice Location Address
First Line	:	214 WASHINGTON ST
Second Line	:
City	:	INGLESIDE
State	:	IL
Zip	:	60041-9208
Country	:	US
Telephone Number	:	847-587-3020
Fax Number	:	847-587-1598

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	04/18/2008

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