Provider Demographics
NPI:1518456672
Name:PARK, MADELINE NAHJIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MADELINE
Middle Name:NAHJIN
Last Name:PARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 OVERLOOK AVE APT 4E
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-2234
Mailing Address - Country:US
Mailing Address - Phone:201-394-4530
Mailing Address - Fax:
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1915
Practice Address - Country:US
Practice Address - Phone:551-996-5593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02740700122300000X
NJ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty