Provider Demographics
NPI:1134551716
Name:PARK, JAE SUNG (DMD)
Entity type:Individual
Prefix:DR
First Name:JAE SUNG
Middle Name:
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 1:1578 CONSTITUTION BLVD
Mailing Address - Street 2:SUITE 01
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-3543
Mailing Address - Country:US
Mailing Address - Phone:803-366-1456
Mailing Address - Fax:
Practice Address - Street 1:1578 CONSTITUTION BLVD
Practice Address - Street 2:SUITE 01
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3543
Practice Address - Country:US
Practice Address - Phone:803-366-1456
Practice Address - Fax:803-324-0117
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.8288 GD1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX8288Medicaid