Provider Demographics
NPI:1124389606
Name:PARK, JILL
Entity Type:Individual
Prefix:DR
First Name:JILL
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 1:400 TECHNOLOGY CENTER DR
Mailing Address - Street 2:APT #4209
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-4714
Mailing Address - Country:US
Mailing Address - Phone:781-580-9081
Mailing Address - Fax:
Practice Address - Street 1:45 MARIANO BISHOP BLVD
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-2346
Practice Address - Country:US
Practice Address - Phone:781-580-9081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18559581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice