Healthcare Provider Details

I. General information

NPI: 1164919981
Provider Name (Legal Business Name): PUYALLUP PARK DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13909 MERIDIAN E STE A1
PUYALLUP WA
98373-9180
US

IV. Provider business mailing address

13909 MERIDIAN E STE A1
PUYALLUP WA
98373-9180
US

V. Phone/Fax

Practice location:
  • Phone: 253-435-0333
  • Fax: 253-435-0362
Mailing address:
  • Phone: 253-435-0333
  • Fax: 253-435-0362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE60048922
License Number StateWA

VIII. Authorized Official

Name: BYUNGJUN PARK
Title or Position: OWNER
Credential: DDS
Phone: 253-435-0333