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General NPI Number Information
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NPI Number | 1578045258
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Entity Type | Organization
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Legal Business Name | JUWON PARK DMD PC
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Dates
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Enumeration Date | 08/30/2018
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Last Update Date | 08/30/2018
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Provider Practice Location Address
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Address Line | 4 EXECUTIVE PARK DR
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City | ALBANY
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State | NY
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Zip | 12203-3718
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Country | US
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Telephone | 347-408-8673
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Fax |
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Provider Business Mailing Address
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Address Line | 255 PATROON CREEK BLVD APT 1405
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City | ALBANY
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State | NY
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Zip | 12206-5019
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Country | US
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Telephone | 347-408-8673
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOHN JUWON PARK
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Credential | DMD
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Telephone | 347-408-8673
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 056491
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License Number State | NY
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