Healthcare Provider Details

I. General information

NPI: 1780200089
Provider Name (Legal Business Name): JI EUN PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 12/29/2023
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 RIVER GREEN PKWY STE 110
DULUTH GA
30096-8333
US

IV. Provider business mailing address

3150 WOODWALK DR SE UNIT 1105
ATLANTA GA
30339-8482
US

V. Phone/Fax

Practice location:
  • Phone: 770-500-3757
  • Fax:
Mailing address:
  • Phone: 706-615-0301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH007607
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: