Provider Demographics
NPI:1164110151
Name:JINO PARK DDS DENTAL CORPORATION
Entity Type:Organization
Organization Name:JINO PARK DDS DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JINO
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-969-3503
Mailing Address - Street 1:24950 REDLANDS BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-4028
Mailing Address - Country:US
Mailing Address - Phone:909-478-9777
Mailing Address - Fax:909-478-9526
Practice Address - Street 1:24950 REDLANDS BLVD STE B
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-4028
Practice Address - Country:US
Practice Address - Phone:909-478-9777
Practice Address - Fax:909-478-9526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-27
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental