1134551716 NPI number — DR. JAE SUNG PARK D.M.D.

Table of content: JENNIFER MORELAND PT, OCS (NPI 1578755062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134551716 NPI number — DR. JAE SUNG PARK D.M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
JAE SUNG
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134551716
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1578 CONSTITUTION BLVD
Provider Second Line Business Mailing Address:
SUITE 01
Provider Business Mailing Address City Name:
ROCK HILL
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29732-3543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-366-1456
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1578 CONSTITUTION BLVD
Provider Second Line Business Practice Location Address:
SUITE 01
Provider Business Practice Location Address City Name:
ROCK HILL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29732-3543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-366-1456
Provider Business Practice Location Address Fax Number:
803-324-0117
Provider Enumeration Date:
08/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DGD.8288 GD , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZX8288 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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