Healthcare Provider Details

I. General information

NPI: 1467756411
Provider Name (Legal Business Name): NAM HEE AVA PARK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2011
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 ABORN RD STE 123
SAN JOSE CA
95121-1584
US

IV. Provider business mailing address

40910 FREMONT BLVD
FREMONT CA
94538-4375
US

V. Phone/Fax

Practice location:
  • Phone: 408-729-9700
  • Fax:
Mailing address:
  • Phone: 510-770-8040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number010437
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number056393
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number056393-1
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number109144
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: