Provider Demographics
NPI:1780200089
Name:PARK, JI EUN
Entity Type:Individual
Prefix:
First Name:JI EUN
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 1:3150 WOODWALK DR SE UNIT 1105
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-8482
Mailing Address - Country:US
Mailing Address - Phone:706-615-0301
Mailing Address - Fax:
Practice Address - Street 1:4855 RIVER GREEN PKWY STE 110
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8333
Practice Address - Country:US
Practice Address - Phone:770-500-3757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-22
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
124Q00000X
GADH007607124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist