Healthcare Provider Details

I. General information

NPI: 1265760474
Provider Name (Legal Business Name): JOHN WOONGJOON PARK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2009
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3866 S 74TH ST STE 200
TACOMA WA
98409-9908
US

IV. Provider business mailing address

6950 NE CAMPUS WAY
HILLSBORO OR
97124-5611
US

V. Phone/Fax

Practice location:
  • Phone: 855-433-6825
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD-4283-PE
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDE00011114
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: