Provider Demographics
NPI:1427424068
Name:PARK, SOHYUN STEPHANIE (DMD)
Entity type:Individual
Prefix:
First Name:SOHYUN
Middle Name:STEPHANIE
Last Name:PARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11311 LA GRANGE AVE APT 327
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6868
Mailing Address - Country:US
Mailing Address - Phone:225-439-3940
Mailing Address - Fax:
Practice Address - Street 1:627 FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-2527
Practice Address - Country:US
Practice Address - Phone:626-799-6255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857026122300000X
CA1024151223P0700X
OH30.0273711223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist