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General NPI Number Information
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NPI Number | 1043615107
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Entity Type | Organization
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Legal Business Name | JONG YUN PARK PLLC
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Dates
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Enumeration Date | 10/30/2014
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Last Update Date | 10/30/2014
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Provider Practice Location Address
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Address Line | 11806 ATLANTIC BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32225-2918
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Country | US
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Telephone | 315-454-6000
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Fax | 315-438-4483
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Provider Business Mailing Address
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Address Line | 11806 ATLANTIC BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32225-2918
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Country | US
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Telephone | 315-454-6000
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Fax | 315-438-4483
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Authorized Official
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Title or Position | PROVIDER RELATIONS
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Name | MIKA WEISS
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Credential |
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Telephone | 315-454-6000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN20765
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License Number State | FL
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