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General NPI Number Information
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NPI Number | 1629110747
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Entity Type | Individual
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Provider Name | JINTAE PARK DDS
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Gender | Male
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Dates
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Enumeration Date | 02/13/2007
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Last Update Date | 01/09/2010
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Provider Practice Location Address
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Address Line | 6795 S VIRGINIA ST E
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City | RENO
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State | NV
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Zip | 89511-1171
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Country | US
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Telephone | 775-853-0503
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Fax | 775-853-0504
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Provider Business Mailing Address
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Address Line | 815 KILEY RANCH PKWY 2901
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City | SPARKS
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State | NV
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Zip | 89436-4066
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Country | US
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Telephone | 626-434-6150
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Fax | 775-657-8619
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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 | 54686
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5678
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License Number State | NV
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