Provider Demographics
NPI:1306981022
Name:KWON, JINSAM
Entity type:Individual
Prefix:
First Name:JINSAM
Middle Name:
Last Name:KWON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16515 MERIDIAN E
Mailing Address - Street 2:SUITE 100B
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-6251
Mailing Address - Country:US
Mailing Address - Phone:253-770-0198
Mailing Address - Fax:253-770-1166
Practice Address - Street 1:16515 MERIDIAN E
Practice Address - Street 2:SUITE 100B
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-6251
Practice Address - Country:US
Practice Address - Phone:253-770-0198
Practice Address - Fax:253-770-1166
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA99831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice