Provider Demographics
NPI:1902333826
Name:GWAK, JI WON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JI WON
Middle Name:
Last Name:GWAK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-2526
Mailing Address - Country:US
Mailing Address - Phone:360-568-5411
Mailing Address - Fax:
Practice Address - Street 1:306 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-2526
Practice Address - Country:US
Practice Address - Phone:360-568-5411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-23
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE.60772219122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist