Provider Demographics
NPI:1285869495
Name:PAK, JUNG SOO (DDS)
Entity type:Individual
Prefix:DR
First Name:JUNG
Middle Name:SOO
Last Name:PAK
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 1:11001 LEE HWY
Mailing Address - Street 2:SUITE # A
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5018
Mailing Address - Country:US
Mailing Address - Phone:703-691-9740
Mailing Address - Fax:703-691-9809
Practice Address - Street 1:11001 LEE HWY
Practice Address - Street 2:SUITE # A
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5018
Practice Address - Country:US
Practice Address - Phone:703-691-9740
Practice Address - Fax:703-691-9809
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014141471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice