Provider Demographics
NPI:1083168538
Name:PAK, ETHELYN JEAN
Entity Type:Individual
Prefix:
First Name:ETHELYN
Middle Name:JEAN
Last Name:PAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 RED OAK DR.
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027
Mailing Address - Country:US
Mailing Address - Phone:615-483-0728
Mailing Address - Fax:
Practice Address - Street 1:440 SAM RIDLEY PKWY W
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-2998
Practice Address - Country:US
Practice Address - Phone:615-625-2955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-12
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10295122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist