Provider Demographics
NPI:1154149227
Name:PARK, PETER SANGHYUK (DDS)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:SANGHYUK
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1887 GREENFIELD AVE APT 310
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-4416
Mailing Address - Country:US
Mailing Address - Phone:213-663-9689
Mailing Address - Fax:
Practice Address - Street 1:1887 GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-4416
Practice Address - Country:US
Practice Address - Phone:213-663-9689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-28
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110407122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist