Provider Demographics
NPI:1306979638
Name:PARK, JOOYOEL
Entity type:Individual
Prefix:DR
First Name:JOOYOEL
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 1:256 S HOBART BLVD
Mailing Address - Street 2:APT #10
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-5248
Mailing Address - Country:US
Mailing Address - Phone:760-969-5469
Mailing Address - Fax:714-571-3560
Practice Address - Street 1:69160 RAMON RD.
Practice Address - Street 2:SUITE #100
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-3343
Practice Address - Country:US
Practice Address - Phone:760-969-5469
Practice Address - Fax:760-770-0280
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55530122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD55530Medicaid