Provider Demographics
NPI:1578045258
Name:JUWON PARK DMD PC
Entity Type:Organization
Organization Name:JUWON PARK DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JUWON
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:347-408-8673
Mailing Address - Street 1:255 PATROON CREEK BLVD APT 1405
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-5019
Mailing Address - Country:US
Mailing Address - Phone:347-408-8673
Mailing Address - Fax:
Practice Address - Street 1:4 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3718
Practice Address - Country:US
Practice Address - Phone:347-408-8673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0564911223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty