Provider Demographics
NPI:1427822147
Name:PARK, JUN HWAN (DMD)
Entity type:Individual
Prefix:
First Name:JUN HWAN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1765 TALLGRASS LN
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-4858
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4039 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-5219
Practice Address - Country:US
Practice Address - Phone:773-782-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0346631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice