Provider Demographics
NPI:1235294299
Name:PARK, JAI (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAI
Middle Name:
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 1:8600 W CHARLESTON BLVD APT 1092
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5411
Mailing Address - Country:US
Mailing Address - Phone:646-229-5387
Mailing Address - Fax:702-671-0333
Practice Address - Street 1:1707 W CHARLESTON BLVD STE 290
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2353
Practice Address - Country:US
Practice Address - Phone:702-671-5139
Practice Address - Fax:702-671-0333
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV55621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice