Healthcare Provider Details

I. General information

NPI: 1083230064
Provider Name (Legal Business Name): JAMES PARK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1979 JESSE JEWELL PKWY SE STE 102
GAINESVILLE GA
30501-2665
US

IV. Provider business mailing address

2735 MCGINNIS FERRY RD UNIT 2220
SUWANEE GA
30024-5810
US

V. Phone/Fax

Practice location:
  • Phone: 917-439-5229
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN124105
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: