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General NPI Number Information
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NPI Number | 1275666315
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Entity Type | Individual
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Provider Name | JAECHAN PARK D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 03/14/2007
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Last Update Date | 03/13/2023
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Provider Practice Location Address
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Address Line | 15201 S WESTERN AVE
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City | GARDENA
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State | CA
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Zip | 90249-4314
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Country | US
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Telephone | 310-400-7705
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Fax |
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Provider Business Mailing Address
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Address Line | 614 INVERNESS CT
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City | FULLERTON
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State | CA
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Zip | 92835-2776
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Country | US
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Telephone | 626-454-0159
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 49972
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License Number State | CA
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