Provider Demographics
NPI:1689044679
Name:PARK, EUN JIN
Entity Type:Individual
Prefix:
First Name:EUN JIN
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 1:801 ATHERTON DR APT 158
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-7961
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2288 DANIELS ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-6706
Practice Address - Country:US
Practice Address - Phone:209-456-5610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA651541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice