Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 101510 | CA |
NPI | 1043731433 |
---|---|
Provider Name | Jessica Kwon |
First Address | Redlands, CA 92373-5859 |
Second Address | Poway, CA 92064-3548 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2017 |
Last Update Date | 10/11/2021 |