Healthcare Provider Details

I. General information

NPI: 1659600682
Provider Name (Legal Business Name): SUE JEAN PARK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2009
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S LAKE AVE # 534
PASADENA CA
91101-3515
US

IV. Provider business mailing address

530 S LAKE AVE # 534
PASADENA CA
91101-3515
US

V. Phone/Fax

Practice location:
  • Phone: 562-201-2221
  • Fax:
Mailing address:
  • Phone: 562-201-2221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number58385
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: