Provider Demographics
NPI:1689891012
Name:JUNG SIM & STEPHEN PARK DENTAL
Entity Type:Organization
Organization Name:JUNG SIM & STEPHEN PARK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUNG
Authorized Official - Middle Name:HYEB
Authorized Official - Last Name:SIM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:562-463-6388
Mailing Address - Street 1:8803 WHITTIER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-2682
Mailing Address - Country:US
Mailing Address - Phone:562-463-6163
Mailing Address - Fax:562-463-6388
Practice Address - Street 1:8803 WHITTIER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-2682
Practice Address - Country:US
Practice Address - Phone:562-463-6163
Practice Address - Fax:562-463-6388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50371284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93082-02Medicare ID - Type UnspecifiedDENTICAL BILLING PROVIDER
CAD50371Medicare ID - Type UnspecifiedRENDERING PROVIDER