Provider Demographics
NPI:1710016514
Name:PARK, JIN S
Entity type:Individual
Prefix:DR
First Name:JIN
Middle Name:S
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JAMES
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:8428 ALONDRA BLVD
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-4406
Mailing Address - Country:US
Mailing Address - Phone:562-633-6566
Mailing Address - Fax:562-633-3308
Practice Address - Street 1:8428 ALONDRA BLVD
Practice Address - Street 2:
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-4406
Practice Address - Country:US
Practice Address - Phone:562-633-6566
Practice Address - Fax:562-633-3308
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB 37476Medicaid