Healthcare Provider Details

I. General information

NPI: 1164552246
Provider Name (Legal Business Name): JIN HWI PARK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 03/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9295 MAGNOLIA AVE #103
RIVERSIDE CA
92503-3800
US

IV. Provider business mailing address

9295 MAGNOLIA AVE #103
RIVERSIDE CA
92503-3800
US

V. Phone/Fax

Practice location:
  • Phone: 917-533-2011
  • Fax:
Mailing address:
  • Phone: 917-533-2011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number051713-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: