Provider Demographics
NPI:1295090611
Name:KWON, EDWIN (DDS)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
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 1:1 WATER ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOYNE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49712-1810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 CARE DR
Practice Address - Street 2:SUITE D
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-5052
Practice Address - Country:US
Practice Address - Phone:517-437-2654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010205111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice