1609258722 NPI number — JUN PARK D.D.S.,P.A.

Table of content: (NPI 1609258722)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609258722 NPI number — JUN PARK D.D.S.,P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JUN PARK D.D.S.,P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1609258722
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1205 YORK RD
Provider Second Line Business Mailing Address:
SUITE 25A
Provider Business Mailing Address City Name:
LUTHERVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21093-6210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-321-6120
Provider Business Mailing Address Fax Number:
410-321-6121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1205 YORK RD
Provider Second Line Business Practice Location Address:
SUITE 25A
Provider Business Practice Location Address City Name:
LUTHERVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21093-6210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-321-6120
Provider Business Practice Location Address Fax Number:
410-321-6121
Provider Enumeration Date:
06/25/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PARK
Authorized Official First Name:
JUN
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
HEAD DENTIST
Authorized Official Telephone Number:
410-321-6120

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  13401 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 15632 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1548443831 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com