Provider Demographics
NPI:1972178036
Name:PARK, CASSIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CASSIE
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 1:3900 PARK AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-3063
Mailing Address - Country:US
Mailing Address - Phone:732-452-0100
Mailing Address - Fax:
Practice Address - Street 1:3900 PARK AVE STE 105
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3063
Practice Address - Country:US
Practice Address - Phone:732-452-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI028430001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program