Provider Demographics
NPI:1033257233
Name:PARK, WONPYO ERIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:WONPYO
Middle Name:ERIC
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 AVENIDA DEL NORTE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-1820
Mailing Address - Country:US
Mailing Address - Phone:714-656-6645
Mailing Address - Fax:
Practice Address - Street 1:11851 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-6825
Practice Address - Country:US
Practice Address - Phone:562-809-8911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010771122300000X
NV4956T1223G0001X
CA56613122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice