Provider Demographics
NPI:1023226768
Name:KWON, JENNIFER K (DMD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:KWON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:386 MAYNARD RD
Mailing Address - Street 2:
Mailing Address - City:SUDBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01776-1280
Mailing Address - Country:US
Mailing Address - Phone:978-440-9918
Mailing Address - Fax:
Practice Address - Street 1:148 LINDEN ST
Practice Address - Street 2:SUITE B-3
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-7900
Practice Address - Country:US
Practice Address - Phone:781-431-7295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA186001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice