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Hwang Oral & Maxillofacial Surgery
Hwang Oral & Maxillofacial Surgery
+1 (541) 972-3903
Dr. Marcus Hwang
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Areas of Concern
Face
Airway
Bite
Temporomandibular Joint
Previous Treatment
Orthodontics
Orthognathic Surgery
Joint Surgery
Suggested Treatment By Referring Doctor
Orthognathic Surgery
Adjunctive Aesthetic Treatment
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