Provider Demographics
NPI:1558718437
Name:PARK, JOHN JOONTAE (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JOONTAE
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 1:8829 HAWTHORNE CT
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-3317
Mailing Address - Country:US
Mailing Address - Phone:410-465-0602
Mailing Address - Fax:
Practice Address - Street 1:9997 SE 82ND AVE
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-2301
Practice Address - Country:US
Practice Address - Phone:503-224-9009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORD106271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program