MEDICARE: DR. JULIUS PARK D.M.D.

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	1223P0221X	Pediatric Dentistry	22DI02198100	NJ
2	1223P0221X	Pediatric Dentistry	050223	NY
3	1223P0221X	Pediatric Dentistry	DN013851	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710022942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JULIUS PARK D.M.D.

Provider Business Mailing Address
First Line	:	1816 EAGLE DR
Second Line	:	200-C
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-8272
Country	:	US
Telephone Number	:	770-926-9260
Fax Number	:	770-926-9263

Provider Business Practice Location Address
First Line	:	1816 EAGLE DR
Second Line	:	200-C
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-8272
Country	:	US
Telephone Number	:	770-926-9260
Fax Number	:	770-926-9263

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

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	09/22/2010

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Directions to “ DR. JULIUS PARK D.M.D.” Practice Location

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