Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | DN21519 | FL |
NPI | 1093198160 |
---|---|
Provider Name | Ms. Mi Ae Kwon |
First Address | Tampa, FL 33629 |
Second Address | Tampa, FL 33629 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2015 |
Last Update Date | 09/11/2018 |