Provider Demographics
NPI:1902131238
Name:PARK, JONGHAN (DMD)
Entity type:Individual
Prefix:DR
First Name:JONGHAN
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 1:16605 E PALISADES BLVD STE 112
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-3716
Mailing Address - Country:US
Mailing Address - Phone:480-837-2000
Mailing Address - Fax:480-837-2078
Practice Address - Street 1:16605 E PALISADES BLVD STE 112
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-3716
Practice Address - Country:US
Practice Address - Phone:480-837-2000
Practice Address - Fax:480-837-2078
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18807122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist