Provider Demographics
NPI:1386968147
Name:PARK, JULIE LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:JULIE
Middle Name:LEE
Last Name:PARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1110 JAEGER ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-2661
Mailing Address - Country:US
Mailing Address - Phone:347-630-1858
Mailing Address - Fax:
Practice Address - Street 1:538 POLARIS PKWY
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-7044
Practice Address - Country:US
Practice Address - Phone:614-682-6213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-23
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0547291223S0112X
PADS0392631223S0112X
OH30.0249431223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery