Provider Demographics
NPI:1710413661
Name:PARK, JUNG MIN
Entity type:Individual
Prefix:
First Name:JUNG MIN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 MOON CHASE LN
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-5363
Mailing Address - Country:US
Mailing Address - Phone:917-683-1392
Mailing Address - Fax:
Practice Address - Street 1:3420 BUFORD DR STE E780
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-8774
Practice Address - Country:US
Practice Address - Phone:678-765-9930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN0157931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program