Provider Demographics
NPI:1184105330
Name:PARK, JAEWOO (DDS)
Entity type:Individual
Prefix:
First Name:JAEWOO
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 CONCORDE CIR UNIT 34419
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:21090-2965
Mailing Address - Country:US
Mailing Address - Phone:714-900-1168
Mailing Address - Fax:
Practice Address - Street 1:100 CRAIN HWY S
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3528
Practice Address - Country:US
Practice Address - Phone:071-490-0116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-26
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0419451223G0001X
MD171531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice