Provider Demographics
NPI:1093365017
Name:PARK, SOYEON
Entity Type:Individual
Prefix:
First Name:SOYEON
Middle Name:
Last Name:PARK
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 1:6806 BANK SIDE DR
Mailing Address - Street 2:
Mailing Address - City:JURUPA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91752-2725
Mailing Address - Country:US
Mailing Address - Phone:415-999-4841
Mailing Address - Fax:
Practice Address - Street 1:3410 GRAND AVE
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-1473
Practice Address - Country:US
Practice Address - Phone:909-364-0027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104386122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist