Healthcare Provider Details

I. General information

NPI: 1629806583
Provider Name (Legal Business Name): PREMIER ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 GRAND AVE STE 204
ENGLEWOOD NJ
07631-6300
US

IV. Provider business mailing address

300 GRAND AVE STE 204
ENGLEWOOD NJ
07631-6300
US

V. Phone/Fax

Practice location:
  • Phone: 201-308-6911
  • Fax:
Mailing address:
  • Phone: 201-308-6911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. JOON PARK
Title or Position: OWNER/ENDODONTIST
Credential: DDS
Phone: 443-465-4065