Provider Demographics
NPI:1427203868
Name:PARK, JAKE YONG (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:YONG
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 1:18707 SE NEWPORT WAY
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-9087
Mailing Address - Country:US
Mailing Address - Phone:206-747-4446
Mailing Address - Fax:
Practice Address - Street 1:12832 SE 40TH LN
Practice Address - Street 2:STE 201
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-1241
Practice Address - Country:US
Practice Address - Phone:425-636-8432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-26
Last Update Date:2014-08-04
Deactivation Date:2012-12-11
Deactivation Code:
Reactivation Date:2013-01-29
Provider Licenses
StateLicense IDTaxonomies
CA56979122300000X
WADE 00011037122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist