Individual
TAE KWON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1161 E SHEPHERD AVE APT 201, FRESNO, CA 93720-2046
(310) 890-0816
Mailing address
777 MAIN ST UNIT 2404, HARTFORD, CT 06103-2325
(310) 890-0816
Taxonomy
Speciality
Code
Description
License number
State
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
103782
CA
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
07/07/2016
Last updated
07/16/2019
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