Provider Demographics
NPI:1962169698
Name:PARK, KRYSTAL SOOJUNG (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:KRYSTAL
Middle Name:SOOJUNG
Last Name:PARK
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2280 EAST SHEPHERD AVENUE
Mailing Address - Street 2:APT. 119
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720
Mailing Address - Country:US
Mailing Address - Phone:530-519-4649
Mailing Address - Fax:
Practice Address - Street 1:7055 N FRESNO ST STE 302
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2957
Practice Address - Country:US
Practice Address - Phone:559-325-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1047181223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty