Healthcare Provider Details

I. General information

NPI: 1366360687
Provider Name (Legal Business Name): BUSUNG PARK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6598 ATLANTIC AVE
LONG BEACH CA
90805-2304
US

IV. Provider business mailing address

6598 ATLANTIC AVE
LONG BEACH CA
90805-2304
US

V. Phone/Fax

Practice location:
  • Phone: 156-261-7123
  • Fax:
Mailing address:
  • Phone: 562-617-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113269
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: