=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235928409
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK LAKEWOOD DENTAL AND DENTURE LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2025
-----------------------------------------------------
Last Update Date | 05/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8717 S TACOMA WAY
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98499-4544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-258-0204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1037 105TH AVENUE CT E
-----------------------------------------------------
City | EDGEWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98372-1327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-258-0204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | JI WOON YOO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 206-258-0204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------