MEDICARE: DR. JONGHAN PARK DMD

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	18807	FL

General Provider Information

NPI Number	:	1902131238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONGHAN PARK DMD

Provider Business Mailing Address
First Line	:	16605 E PALISADES BLVD STE 112
Second Line	:
City	:	FOUNTAIN HILLS
State	:	AZ
Zip	:	85268-3716
Country	:	US
Telephone Number	:	480-837-2000
Fax Number	:	480-837-2078

Provider Business Practice Location Address
First Line	:	16605 E PALISADES BLVD STE 112
Second Line	:
City	:	FOUNTAIN HILLS
State	:	AZ
Zip	:	85268-3716
Country	:	US
Telephone Number	:	480-837-2000
Fax Number	:	480-837-2078

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

Provider Enumeration Date	:	10/05/2009
Last Update Date	:	06/26/2020

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