Healthcare Provider Details

I. General information

NPI: 1336556703
Provider Name (Legal Business Name): SUNYOUNG PARK DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 02/23/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 NW CENTURY DR STE 200
CORVALLIS OR
97330-3495
US

IV. Provider business mailing address

2350 NW CENTURY DR STE 200
CORVALLIS OR
97330-3495
US

V. Phone/Fax

Practice location:
  • Phone: 541-768-0419
  • Fax:
Mailing address:
  • Phone: 541-768-0419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number726515
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: