Provider Demographics
NPI:1033668355
Name:KWAK, JAE H (DMD)
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:H
Last Name:KWAK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24635 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-9751
Mailing Address - Country:US
Mailing Address - Phone:469-449-3162
Mailing Address - Fax:
Practice Address - Street 1:1631 EDINGER AVE STE 105
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6537
Practice Address - Country:US
Practice Address - Phone:714-717-3757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-28
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32379122300000X
CA1025241223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist