Provider Demographics
NPI:1639535560
Name:PARK, HYUNJUNG
Entity Type:Individual
Prefix:
First Name:HYUNJUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N CLARK ST FL 6
Mailing Address - Street 2:DENTAL DREAMS LLC C/O JULIETTE BOYCE
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-4712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 CENTRAL AVE NW STE F1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-1669
Practice Address - Country:US
Practice Address - Phone:505-843-7172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD4432122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist