MEDICARE: SUNGHAE PARK DMD

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	1223G0001X	General Practice Dentistry	57834	CA

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	:	1760470769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUNGHAE PARK DMD

Provider Business Mailing Address
First Line	:	16709 HAWTHORNE BLVD
Second Line	:
City	:	LAWNDALE
State	:	CA
Zip	:	90260-3244
Country	:	US
Telephone Number	:	310-542-5558
Fax Number	:	310-542-4309

Provider Business Practice Location Address
First Line	:	16709 HAWTHORNE BLVD
Second Line	:
City	:	LAWNDALE
State	:	CA
Zip	:	90260-3244
Country	:	US
Telephone Number	:	310-542-5558
Fax Number	:	310-542-4309

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

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	10/31/2016

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Directions to “ SUNGHAE PARK DMD” Practice Location

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