Provider Demographics
NPI:1568597912
Name:PARK, YOUNG BAE (DDS)
Entity Type:Individual
Prefix:DR
First Name:YOUNG
Middle Name:BAE
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 1:11120 EVERGREEN WAY
Mailing Address - Street 2:#G
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-3888
Mailing Address - Country:US
Mailing Address - Phone:425-265-1188
Mailing Address - Fax:
Practice Address - Street 1:11120 EVERGREEN WAY
Practice Address - Street 2:#G
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-3888
Practice Address - Country:US
Practice Address - Phone:425-265-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE74651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA33-1093673Medicaid