Healthcare Provider Details

I. General information

NPI: 1427822147
Provider Name (Legal Business Name): JUN HWAN PARK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2023
Last Update Date: 03/08/2026
Certification Date: 03/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 WASHINGTON AVE STE F2
MT PLEASANT WI
53406-4000
US

IV. Provider business mailing address

1765 TALLGRASS LN
LAKE FOREST IL
60045-4858
US

V. Phone/Fax

Practice location:
  • Phone: 262-999-9998
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6001735
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.034663
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: