Provider Demographics
NPI:1982816542
Name:KWON, HENRY SANG (DDS)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:SANG
Last Name:KWON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2836 W RIALTO AVE # A
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-6743
Mailing Address - Country:US
Mailing Address - Phone:909-820-9454
Mailing Address - Fax:909-820-9482
Practice Address - Street 1:2836 W RIALTO AVE # A
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-6743
Practice Address - Country:US
Practice Address - Phone:909-820-9454
Practice Address - Fax:909-820-9482
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA475051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA520924OtherDENTI-CAL PIN #