Healthcare Provider Details

I. General information

NPI: 1801246715
Provider Name (Legal Business Name): JIN PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CHURCH ST SE STE 102
SALEM OR
97301-3758
US

IV. Provider business mailing address

250 CHURCH ST SE STE 102
SALEM OR
97301-3758
US

V. Phone/Fax

Practice location:
  • Phone: 503-581-1999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD12135
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: