Provider Demographics
NPI:1558718437
Name:PARK, JOHN JOONTAE (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JOONTAE
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 1:2100 NE BROADWAY ST STE 205
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1500
Mailing Address - Country:US
Mailing Address - Phone:503-284-2893
Mailing Address - Fax:503-287-2016
Practice Address - Street 1:2100 NE BROADWAY ST STE 205
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1500
Practice Address - Country:US
Practice Address - Phone:503-284-2893
Practice Address - Fax:503-287-2016
Is Sole Proprietor?:No
Enumeration Date:2016-05-19
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORD106271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program