Provider Demographics
NPI:1629110747
Name:PARK, JINTAE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JINTAE
Middle Name:
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 1:815 KILEY RANCH PKWY
Mailing Address - Street 2:2901
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89436-4066
Mailing Address - Country:US
Mailing Address - Phone:626-434-6150
Mailing Address - Fax:775-657-8619
Practice Address - Street 1:6795 S VIRGINIA ST
Practice Address - Street 2:E
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-1171
Practice Address - Country:US
Practice Address - Phone:775-853-0503
Practice Address - Fax:775-853-0504
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2010-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54686122300000X
NV5678122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD54686Medicaid