Provider Demographics
NPI:1366642027
Name:PARK, JIN SEO (DDS)
Entity Type:Individual
Prefix:
First Name:JIN
Middle Name:SEO
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 1:2727 W OLYMPIC BLVD
Mailing Address - Street 2:301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2637
Mailing Address - Country:US
Mailing Address - Phone:213-385-8000
Mailing Address - Fax:
Practice Address - Street 1:2727 W OLYMPIC BLVD
Practice Address - Street 2:301
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2637
Practice Address - Country:US
Practice Address - Phone:213-385-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA474061223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD47406OtherCALIFORNIA CHILDRENS SERV
CAD47406OtherDENTI CAL