Healthcare Provider Details

I. General information

NPI: 1942200050
Provider Name (Legal Business Name): CHUNG-JAE PARK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 04/01/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21035 SW PACIFIC COAST HWY STE 100
SHERWOOD OR
97140
US

IV. Provider business mailing address

21035 SW PACIFIC HWY STE 100
SHERWOOD OR
97140-8036
US

V. Phone/Fax

Practice location:
  • Phone: 503-925-1473
  • Fax: 503-925-1479
Mailing address:
  • Phone: 503-575-4864
  • Fax: 503-966-3993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD8095
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: