Healthcare Provider Details

I. General information

NPI: 1639532104
Provider Name (Legal Business Name): JOSEPH PARK DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 ROCK MERRITT AVE
FORT BRAGG NC
28310-0001
US

IV. Provider business mailing address

2817 ROCK MERRITT AVE
FORT BRAGG NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number13022
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number13022
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: