Provider Demographics
NPI:1942557962
Name:PARK, JEANETTE GENKYUNG (RDH)
Entity Type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:GENKYUNG
Last Name:PARK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6350 W RAMSEY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-3062
Mailing Address - Country:US
Mailing Address - Phone:951-769-0466
Mailing Address - Fax:951-769-3606
Practice Address - Street 1:6350 W RAMSEY ST
Practice Address - Street 2:SUITE A
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3062
Practice Address - Country:US
Practice Address - Phone:951-769-0466
Practice Address - Fax:951-769-3606
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23312124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist