Provider Demographics
NPI:1134342629
Name:PARK, JACOB GYEONGIL (DDS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:GYEONGIL
Last Name:PARK
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 1:7434 LOUIS PASTEUR DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4538
Mailing Address - Country:US
Mailing Address - Phone:210-615-7224
Mailing Address - Fax:210-615-7229
Practice Address - Street 1:7434 LOUIS PASTEUR DR
Practice Address - Street 2:SUITE 303
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4538
Practice Address - Country:US
Practice Address - Phone:210-615-7224
Practice Address - Fax:210-615-7229
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17106122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist