Provider Demographics
NPI:1194908731
Name:KWON, JAY (DMD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:KWON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:JAE
Other - Middle Name:
Other - Last Name:KWON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:4026 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-3257
Mailing Address - Country:US
Mailing Address - Phone:213-925-7148
Mailing Address - Fax:
Practice Address - Street 1:4026 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-3257
Practice Address - Country:US
Practice Address - Phone:323-272-4271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2025-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA566561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice