Provider Demographics
NPI:1164552246
Name:PARK, JIN HWI (DDS)
Entity Type:Individual
Prefix:DR
First Name:JIN
Middle Name:HWI
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9295 MAGNOLIA AVE
Mailing Address - Street 2:#103
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3800
Mailing Address - Country:US
Mailing Address - Phone:917-533-2011
Mailing Address - Fax:
Practice Address - Street 1:9295 MAGNOLIA AVE
Practice Address - Street 2:#103
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3800
Practice Address - Country:US
Practice Address - Phone:917-533-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051713-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist