Provider Demographics
NPI:1710545637
Name:PARK, SI-EUN (DMD)
Entity Type:Individual
Prefix:
First Name:SI-EUN
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 1:1374 SYNERGY
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-0160
Mailing Address - Country:US
Mailing Address - Phone:330-631-3238
Mailing Address - Fax:
Practice Address - Street 1:4050 BARRANCA PKWY STE 100
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-1725
Practice Address - Country:US
Practice Address - Phone:949-861-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1053151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice