Healthcare Provider Details

I. General information

NPI: 1659749612
Provider Name (Legal Business Name): JOO HYOUNG PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 ROUTE 46 STE 2-7A
MOUNTAIN LAKES NJ
07046-1743
US

IV. Provider business mailing address

333 ROUTE 46 STE 2-7A
MOUNTAIN LAKES NJ
07046-1743
US

V. Phone/Fax

Practice location:
  • Phone: 862-286-8895
  • Fax:
Mailing address:
  • Phone: 862-286-8895
  • Fax: 862-286-8893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number061725
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number22DI02955500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: