MEDICARE: PETER SANGHYUK PARK DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	110407	CA

General Provider Information

NPI Number	:	1154149227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER SANGHYUK PARK DDS

Provider Business Mailing Address
First Line	:	1887 GREENFIELD AVE APT 310
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-4416
Country	:	US
Telephone Number	:	213-663-9689
Fax Number	:

Provider Business Practice Location Address
First Line	:	1887 GREENFIELD AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-4416
Country	:	US
Telephone Number	:	213-663-9689
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2024
Last Update Date	:	09/28/2024

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