Provider Demographics
NPI:1073526794
Name:PARK, RENEE YOOSUN (DDS)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:YOOSUN
Last Name:PARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10255 BLACK MOUNTAIN RD
Mailing Address - Street 2:#P4
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-3866
Mailing Address - Country:US
Mailing Address - Phone:510-290-2260
Mailing Address - Fax:
Practice Address - Street 1:10255 BLACK MOUNTAIN RD
Practice Address - Street 2:#P4
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-3866
Practice Address - Country:US
Practice Address - Phone:510-290-2260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54005122300000X
NY055807-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist