Provider Demographics
NPI:1093238610
Name:PARK, EUIJOON
Entity type:Individual
Prefix:
First Name:EUIJOON
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8749 E 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80238-3138
Mailing Address - Country:US
Mailing Address - Phone:216-392-3729
Mailing Address - Fax:
Practice Address - Street 1:11175 E MISSISSIPPI AVE STE 110
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-3137
Practice Address - Country:US
Practice Address - Phone:303-723-9631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN29562122300000X
CO00205471122300000X
CA101669122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist