Organization
EVERGREEN DENTAL GROUP, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. CHIA HUI JENNY KWON (PART OWNER/ DENTIST)
(917) 453-4055
Entity
Organization
Contact information
Practice address
34 EVERGREEN WAY, SOUTH WINDSOR, CT 06074-6976
(917) 453-4055
Mailing address
34 EVERGREEN WAY, SOUTH WINDSOR, CT 06074-6976
(917) 453-4055
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
010110
CT
1223G0001X
General Practice Dentistry
010241
CT
1223P0221X
Pediatric Dentistry
010004
CT
Other
Enumeration date
04/14/2011
Last updated
04/14/2011
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