Healthcare Provider Details

I. General information

NPI: 1174903660
Provider Name (Legal Business Name): JONG HOON PARK D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

885 SMITHFIELD AVE
LINCOLN RI
02865-3508
US

IV. Provider business mailing address

40 NOUVELLE WAY UNIT N147
NATICK MA
01760-1599
US

V. Phone/Fax

Practice location:
  • Phone: 401-723-7020
  • Fax:
Mailing address:
  • Phone: 714-757-2525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN03363
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN1856894
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: