Provider Demographics
NPI:1861624405
Name:PARK, JI EUN (DDS)
Entity type:Individual
Prefix:DR
First Name:JI
Middle Name:EUN
Last Name:PARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25-37 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106
Mailing Address - Country:US
Mailing Address - Phone:718-786-2631
Mailing Address - Fax:
Practice Address - Street 1:25-37 BROADWAY
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106
Practice Address - Country:US
Practice Address - Phone:718-786-2631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-16
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054533122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03142927Medicaid