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General NPI Number Information
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NPI Number | 1043101074
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Entity Type | Individual
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Provider Name | JAE MIN PARK DDS
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Gender | Male
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Dates
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Enumeration Date | 07/09/2025
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Last Update Date | 09/05/2025
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Provider Practice Location Address
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Address Line | 185 MAIN ST
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City | WATERVILLE
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State | ME
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Zip | 04901-6625
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Country | US
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Telephone | 833-201-0170
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Fax |
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Provider Business Mailing Address
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Address Line | 3203-300 FRONT STREET WEST
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City | TORONTO
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State | ONTARIO
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Zip | M5V0E9
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Country | CA
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN10000826
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License Number State | MA
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