Provider Demographics
NPI:1205813227
Name:PARK, JOSEPH WON-JOON (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:WON-JOON
Last Name:PARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 SAINT JULIAN PL
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2409
Mailing Address - Country:US
Mailing Address - Phone:803-254-2972
Mailing Address - Fax:803-799-2151
Practice Address - Street 1:1755 SAINT JULIAN PL
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2409
Practice Address - Country:US
Practice Address - Phone:803-254-2972
Practice Address - Fax:803-799-2151
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36131223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3613Medicaid
SCZX3613Medicaid