Provider Demographics
NPI:1992017461
Name:PARK, JIN WOO (DMD)
Entity type:Individual
Prefix:
First Name:JIN
Middle Name:WOO
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 1:1607 W HENDERSON ST STE #K
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033
Mailing Address - Country:US
Mailing Address - Phone:817-522-3166
Mailing Address - Fax:817-522-3168
Practice Address - Street 1:1607 W HENDERSON ST STE K
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4179
Practice Address - Country:US
Practice Address - Phone:817-522-3166
Practice Address - Fax:817-522-3168
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29792122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist