Provider Demographics
NPI:1013581677
Name:PARK, JAY (DMD)
Entity Type:Individual
Prefix:
First Name:JAY
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 1:12319 41ST STREET CT E
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98372-7801
Mailing Address - Country:US
Mailing Address - Phone:931-494-6959
Mailing Address - Fax:
Practice Address - Street 1:1404 LAKE TAPPS PKWY SE STE A103
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98092-8156
Practice Address - Country:US
Practice Address - Phone:253-341-4973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE611640361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice