Provider Demographics
NPI:1376114207
Name:PARK, SCOTT JUYOUNG (DMD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:JUYOUNG
Last Name:PARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:JU
Other - Middle Name:YOUNG
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4632 DANDELION CIR NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-3660
Mailing Address - Country:US
Mailing Address - Phone:404-313-6654
Mailing Address - Fax:
Practice Address - Street 1:7155 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2908
Practice Address - Country:US
Practice Address - Phone:678-904-5166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-01
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1223761223G0001X, 390200000X
WI1002618-151223G0001X
IL019.0334401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223G0001XDental ProvidersDentistGeneral Practice