Provider Demographics
NPI:1902566003
Name:PARK DENTISTRY LLC
Entity Type:Organization
Organization Name:PARK DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOON JAE
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-545-6747
Mailing Address - Street 1:1947 S 60TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53219-1552
Mailing Address - Country:US
Mailing Address - Phone:414-545-6747
Mailing Address - Fax:414-545-2488
Practice Address - Street 1:1947 S 60TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53219-1552
Practice Address - Country:US
Practice Address - Phone:414-545-6747
Practice Address - Fax:414-545-2488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty