Provider Demographics
NPI:1902015415
Name:PARK, YONG S (DMD)
Entity Type:Individual
Prefix:DR
First Name:YONG
Middle Name:S
Last Name:PARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 UNIVERSITY BLVD N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-9230
Mailing Address - Country:US
Mailing Address - Phone:904-253-2062
Mailing Address - Fax:904-253-1942
Practice Address - Street 1:515 WEST 6TH STREET
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206
Practice Address - Country:US
Practice Address - Phone:904-253-1210
Practice Address - Fax:904-253-1956
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN134131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0007116-00Medicaid