Provider Demographics
NPI:1194879965
Name:PARK, SOONJIN (DDS)
Entity type:Individual
Prefix:MRS
First Name:SOONJIN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10643 PROFESSIONAL CIR # 102
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-5851
Mailing Address - Country:US
Mailing Address - Phone:775-737-4035
Mailing Address - Fax:775-737-4036
Practice Address - Street 1:10643 PROFESSIONAL CIR # 102
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-5851
Practice Address - Country:US
Practice Address - Phone:775-737-4035
Practice Address - Fax:775-737-4036
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA547721223G0001X
NV5588122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice