Provider Demographics
NPI:1386327690
Name:PARK, BUMSOO (DDS)
Entity type:Individual
Prefix:DR
First Name:BUMSOO
Middle Name:
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 1:1115 S SANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-9047
Mailing Address - Country:US
Mailing Address - Phone:951-404-5307
Mailing Address - Fax:951-905-1760
Practice Address - Street 1:1115 S SANDERSON AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-9047
Practice Address - Country:US
Practice Address - Phone:951-404-5307
Practice Address - Fax:951-905-1760
Is Sole Proprietor?:No
Enumeration Date:2023-08-11
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109034122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist