Provider Demographics
NPI:1164919981
Name:PUYALLUP PARK DENTAL
Entity type:Organization
Organization Name:PUYALLUP PARK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BYUNGJUN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-435-0333
Mailing Address - Street 1:13909 MERIDIAN E STE A1
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-9180
Mailing Address - Country:US
Mailing Address - Phone:253-435-0333
Mailing Address - Fax:253-435-0362
Practice Address - Street 1:13909 MERIDIAN E STE A1
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-9180
Practice Address - Country:US
Practice Address - Phone:253-435-0333
Practice Address - Fax:253-435-0362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE600489221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty