Healthcare Provider Details

I. General information

NPI: 1760561450
Provider Name (Legal Business Name): STEPHEN JIN PARK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 W 34TH ST # 124C
LOS ANGELES CA
90089-0058
US

IV. Provider business mailing address

901 NORTHAMPTON WAY
FULLERTON CA
92833-1413
US

V. Phone/Fax

Practice location:
  • Phone: 213-740-0655
  • Fax:
Mailing address:
  • Phone: 714-732-0369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number49971
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: