Healthcare Provider Details

I. General information

NPI: 1700570686
Provider Name (Legal Business Name): JIHYEON PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4519 WOODRUFF RD STE 10
COLUMBUS GA
31904-6091
US

IV. Provider business mailing address

6734 BECK BLVD UNIT 29
COLUMBUS GA
31904-3391
US

V. Phone/Fax

Practice location:
  • Phone: 470-524-6317
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN124198
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: