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General NPI Number Information
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NPI Number | 1407789829
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Entity Type | Individual
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Provider Name | YONG JIN PARK
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Gender | Male
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Dates
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Enumeration Date | 06/05/2026
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Last Update Date | 06/05/2026
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Provider Practice Location Address
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Address Line | SEVERANCE DENTAL CLINIC, #206 YONGHEON B/D, SEONBU-DONG 1076-3
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City | ANSAN
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State | GYEONGGI-DO
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Zip | 15239
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Country | KR
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Telephone |
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Fax |
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Provider Business Mailing Address
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Address Line | 321 E DAVID DR
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City | FLAGSTAFF
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State | AZ
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Zip | 86001-3243
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Country | US
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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 | 112682
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License Number State | CA
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