MEDICARE: PARK DENTAL GROUP, LLC

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	1223G0001X	General Practice Dentistry	8288	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275908923
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK DENTAL GROUP, LLC

Provider Business Mailing Address
First Line	:	1578 CONSTITUTION BLVD
Second Line	:	STE 01
City	:	ROCK HILL
State	:	SC
Zip	:	29732-3543
Country	:	US
Telephone Number	:	803-366-1456
Fax Number	:	803-324-0117

Provider Business Practice Location Address
First Line	:	1578 CONSTITUTION BLVD
Second Line	:	STE 01
City	:	ROCK HILL
State	:	SC
Zip	:	29732-3543
Country	:	US
Telephone Number	:	803-366-1456
Fax Number	:	803-324-0117

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JAE SUNG PARK
Credential	:
Telephone Number	:	803-366-1456

Provider Enumeration Date	:	12/07/2015
Last Update Date	:	12/07/2015

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