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General NPI Number Information
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NPI Number | 1659749612
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Entity Type | Individual
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Provider Name | JOO HYOUNG PARK
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Gender | Male
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Dates
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Enumeration Date | 09/08/2015
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Last Update Date | 07/15/2021
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Provider Practice Location Address
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Address Line | 625 ELMWOOD AVE
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City | ROCHESTER
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State | NY
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Zip | 14620-2913
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Country | US
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Telephone | 585-275-5051
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Fax |
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Provider Business Mailing Address
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Address Line | 350 N CLARK ST FL 6 DENTAL DREAMS LLC C/O DANIELLE THARP
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City | CHICAGO
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State | IL
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Zip | 60654-4712
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.030227
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 061725
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License Number State | NY
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