Provider Demographics
NPI:1396736989
Name:PARK, JOSEPH S (DDS)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:S
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 1:412 STATE ROUTE 37
Mailing Address - Street 2:
Mailing Address - City:HOGANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13655-3109
Mailing Address - Country:US
Mailing Address - Phone:518-358-3141
Mailing Address - Fax:518-358-2797
Practice Address - Street 1:412 STATE ROUTE 37
Practice Address - Street 2:
Practice Address - City:HOGANSBURG
Practice Address - State:NY
Practice Address - Zip Code:13655-3109
Practice Address - Country:US
Practice Address - Phone:518-358-3141
Practice Address - Fax:518-358-2797
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0511251122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO89875818Medicaid
NM44007027Medicaid
NY03078080Medicaid
AZ852708Medicaid