Provider Demographics
NPI:1255984324
Name:PARK, JI WON (DMD)
Entity type:Individual
Prefix:
First Name:JI WON
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 1:11 PERIMETER CTR E APT 2304
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30346-1650
Mailing Address - Country:US
Mailing Address - Phone:404-428-4851
Mailing Address - Fax:
Practice Address - Street 1:1605 ROBERTA DR SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30008-3855
Practice Address - Country:US
Practice Address - Phone:770-419-3120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0158751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice