MEDICARE: DAVID 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	19025550	IL

General Provider Information

NPI Number	:	1982793493
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID KWON D.D.S

Provider Business Mailing Address
First Line	:	610 CRYSTAL POINT DR
Second Line	:	SUITE 4
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-1401
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	610 CRYSTAL POINT DR
Second Line	:	SUITE 4
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-1401
Country	:	US
Telephone Number	:	815-356-1920
Fax Number	:

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

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/08/2007

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