=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659745644
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAK DENTAL INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2015
-----------------------------------------------------
Last Update Date | 01/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 888 BREA CANYON RD STE 360
-----------------------------------------------------
City | DIAMOND BAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91789-3096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-404-2222
-----------------------------------------------------
Fax | 626-965-5685
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 888 BREA CANYON RD STE 360
-----------------------------------------------------
City | DIAMOND BAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91789-3096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-404-2222
-----------------------------------------------------
Fax | 626-965-5685
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JONGSON PAK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 626-404-2222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 41507
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------