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General NPI Number Information
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NPI Number | 1720791817
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Entity Type | Organization
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Legal Business Name | PARK FAMILY DENTAL LLC
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Dates
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Enumeration Date | 01/04/2023
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Last Update Date | 01/04/2023
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Provider Practice Location Address
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Address Line | 1001 MADISON AVE
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City | SOUTH MILWAUKEE
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State | WI
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Zip | 53172-2500
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Country | US
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Telephone | 414-203-9664
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Fax |
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Provider Business Mailing Address
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Address Line | W201N5244 SANDPIPER LN
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City | MENOMONEE FALLS
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State | WI
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Zip | 53051-6209
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Country | US
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Telephone | 262-720-4669
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOON JAE PARK
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Credential | DDS
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Telephone | 262-720-4669
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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