Provider Demographics
NPI:1609636810
Name:JC PARK DDS INC
Entity Type:Organization
Organization Name:JC PARK DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAECHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-454-0159
Mailing Address - Street 1:15201 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-4314
Mailing Address - Country:US
Mailing Address - Phone:310-400-7705
Mailing Address - Fax:310-400-7714
Practice Address - Street 1:1505 S RIVERSIDE AVE UNIT B
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-7725
Practice Address - Country:US
Practice Address - Phone:909-440-5345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental