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General NPI Number Information
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NPI Number | 1164919981
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Entity Type | Organization
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Legal Business Name | PUYALLUP PARK DENTAL
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Dates
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Enumeration Date | 04/17/2018
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Last Update Date | 04/17/2018
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Provider Practice Location Address
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Address Line | 13909 MERIDIAN E STE A1
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City | PUYALLUP
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State | WA
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Zip | 98373-9180
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Country | US
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Telephone | 253-435-0333
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Fax | 253-435-0362
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Provider Business Mailing Address
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Address Line | 13909 MERIDIAN E STE A1
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City | PUYALLUP
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State | WA
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Zip | 98373-9180
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Country | US
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Telephone | 253-435-0333
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Fax | 253-435-0362
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Authorized Official
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Title or Position | OWNER
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Name | BYUNGJUN PARK
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Credential | DDS
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Telephone | 253-435-0333
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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 | DE60048922
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License Number State | WA
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