Provider Demographics
NPI:1255453668
Name:JIN PARK DDS, INC
Entity type:Organization
Organization Name:JIN PARK DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-385-8000
Mailing Address - Street 1:2727 W OLYMPIC BLVD
Mailing Address - Street 2:301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2637
Mailing Address - Country:US
Mailing Address - Phone:213-385-8000
Mailing Address - Fax:
Practice Address - Street 1:2727 W OLYMPIC BLVD
Practice Address - Street 2:301
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2637
Practice Address - Country:US
Practice Address - Phone:213-385-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-05
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA474061223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD47406Medicaid
CA47406OtherCA CHILDREN'S SERVICES