Provider Demographics
NPI:1215638713
Name:JC PARK DENTAL GROUP, INC.
Entity type:Organization
Organization Name:JC PARK DENTAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAECHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-454-0159
Mailing Address - Street 1:614 INVERNESS CT
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-2776
Mailing Address - Country:US
Mailing Address - Phone:626-454-0159
Mailing Address - Fax:
Practice Address - Street 1:15201 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-4314
Practice Address - Country:US
Practice Address - Phone:310-400-7705
Practice Address - Fax:310-400-7714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental