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General NPI Number Information
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NPI Number | 1518176023
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Entity Type | Organization
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Legal Business Name | MY DENTIST AND ASSOCIATES, P.A.
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 12220 ATLANTIC BLVD SUITE #128
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City | JACKSONVILLE
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State | FL
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Zip | 32225-5822
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Country | US
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Telephone | 904-221-8221
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Fax |
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Provider Business Mailing Address
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Address Line | 12220 ATLANTIC BLVD SUITE #128
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City | JACKSONVILLE
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State | FL
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Zip | 32225-5822
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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 | PRESIDENT
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Name | DR. YONG PARK
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Credential |
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Telephone | 904-221-8221
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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 | DN13413
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License Number State | FL
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