Provider Demographics
NPI:1528139623
Name:PARK, WON BO (DDS)
Entity type:Individual
Prefix:DR
First Name:WON
Middle Name:BO
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 1:1105 S EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-2850
Mailing Address - Country:US
Mailing Address - Phone:714-738-0304
Mailing Address - Fax:714-213-8394
Practice Address - Street 1:3663 W 6TH ST STE 110
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020
Practice Address - Country:US
Practice Address - Phone:213-380-1767
Practice Address - Fax:213-380-2419
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA400481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice