Healthcare Provider Details

I. General information

NPI: 1740482694
Provider Name (Legal Business Name): OOLI ORTHODONTICS - AZ, PHX, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 06/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W GLENDALE AVE SUITE #3
PHOENIX AZ
85021-9701
US

IV. Provider business mailing address

6200 S MCCLINTOCK DR SUITE #4
TEMPE AZ
85283-3268
US

V. Phone/Fax

Practice location:
  • Phone: 480-777-7759
  • Fax: 480-777-7120
Mailing address:
  • Phone: 480-777-7759
  • Fax: 480-777-7120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6542
License Number StateAZ

VIII. Authorized Official

Name: DR. WON-WOO PARK
Title or Position: PRESIDENT
Credential: D.M.D., M.S.
Phone: 480-777-7759