MEDICARE: DR. JAMES PARK D.M.D

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	DN 21873	FL
2	1223G0001X	General Practice Dentistry	DN123428	GA

General Provider Information

NPI Number	:	1245689728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES PARK D.M.D

Provider Business Mailing Address
First Line	:	1175 PEACHTREE ST NE STE 1210
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30361-3544
Country	:	US
Telephone Number	:	404-874-6464
Fax Number	:

Provider Business Practice Location Address
First Line	:	1175 PEACHTREE ST NE STE 1210
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30361-3544
Country	:	US
Telephone Number	:	404-874-6464
Fax Number	:

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

Provider Enumeration Date	:	06/06/2016
Last Update Date	:	03/21/2025

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