Provider Demographics
NPI:1497323315
Name:PARK, LUCIENNE (DMD)
Entity type:Individual
Prefix:
First Name:LUCIENNE
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 1:5753 BEACH BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5753 BEACH BLVD STE 4
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5128
Practice Address - Country:US
Practice Address - Phone:904-441-1642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN270061223G0001X, 1223G0001X
AZD012242122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty