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General NPI Number Information
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NPI Number | 1568817559
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Entity Type | Individual
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Provider Name | JOON-JAE PARK
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Gender | Male
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Dates
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Enumeration Date | 04/27/2016
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Last Update Date | 07/16/2016
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Provider Practice Location Address
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Address Line | S63W13660 JANESVILLE RD
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City | MUSKEGO
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State | WI
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Zip | 53150-2713
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Country | US
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Telephone | 262-720-4669
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Fax |
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Provider Business Mailing Address
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Address Line | 515 S GRANDVIEW BLVD
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City | WAUKESHA
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State | WI
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Zip | 53188-4792
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 1001390-15
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License Number State | WI
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