Provider Demographics
NPI:1588785521
Name:PARK, JACLYN J (DDS)
Entity type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:J
Last Name:PARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E 57TH ST
Mailing Address - Street 2:SUITE #1520
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2049
Mailing Address - Country:US
Mailing Address - Phone:212-759-7303
Mailing Address - Fax:212-750-8929
Practice Address - Street 1:115 E 57TH ST
Practice Address - Street 2:SUITE#1520
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2049
Practice Address - Country:US
Practice Address - Phone:212-759-7303
Practice Address - Fax:212-750-8929
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0437311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY133776537OtherTIN