Provider Demographics
NPI:1457081101
Name:PARK, JANICE CARMEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JANICE
Middle Name:CARMEN
Last Name:PARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 SAVANNAH DR
Mailing Address - Street 2:
Mailing Address - City:SENOIA
Mailing Address - State:GA
Mailing Address - Zip Code:30276-2357
Mailing Address - Country:US
Mailing Address - Phone:830-319-2761
Mailing Address - Fax:
Practice Address - Street 1:2513 REDWINE RD STE C
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-4420
Practice Address - Country:US
Practice Address - Phone:770-486-1984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1226941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty