MEDICARE: JIHYE PARK DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	22DI02485600	NJ
2	1223G0001X	General Practice Dentistry	22DI02485600	NJ

General Provider Information

NPI Number	:	1699047480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIHYE PARK DDS

Provider Business Mailing Address
First Line	:	1567 PALISADE AVE STE 2A
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-6923
Country	:	US
Telephone Number	:	201-568-3424
Fax Number	:

Provider Business Practice Location Address
First Line	:	1567 PALISADE AVE STE 2A
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-6923
Country	:	US
Telephone Number	:	201-568-3424
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2012
Last Update Date	:	02/26/2025

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