Provider Demographics
NPI:1609484757
Name:KWON, STEPHEN SOONBEOM (DMD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:SOONBEOM
Last Name:KWON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 DARTMOUTH DR
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-1005
Mailing Address - Country:US
Mailing Address - Phone:516-240-3777
Mailing Address - Fax:
Practice Address - Street 1:2035 LAKEVILLE RD STE 205
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1661
Practice Address - Country:US
Practice Address - Phone:516-437-1633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0637741223E0200X
MADN1858976122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty