Healthcare Provider Details

I. General information

NPI: 1386110781
Provider Name (Legal Business Name): JAE H PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3259 CATLIN AVE
QUANTICO VA
22134-5109
US

IV. Provider business mailing address

2701 NEABSCO COMMON PL APT 519
WOODBRIDGE VA
22191-6717
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-9000
  • Fax:
Mailing address:
  • Phone: 703-254-8008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401416211
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: