Provider Demographics
NPI:1699392316
Name:PARK, JOOYEON (DMD)
Entity Type:Individual
Prefix:
First Name:JOOYEON
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 LOCUST ST FL 3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5400
Mailing Address - Country:US
Mailing Address - Phone:215-780-1809
Mailing Address - Fax:215-309-1129
Practice Address - Street 1:1207 CHESTNUT ST FL 4
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4131
Practice Address - Country:US
Practice Address - Phone:215-525-3046
Practice Address - Fax:215-309-1133
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS043036122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA104059920Medicaid