Provider Demographics
NPI:1669797296
Name:WON BO PARK DDS APC
Entity type:Organization
Organization Name:WON BO PARK DDS APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:YUNSUK
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-263-7768
Mailing Address - Street 1:1105 S. EUCLID ST. SUITE E
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832
Mailing Address - Country:US
Mailing Address - Phone:714-738-0304
Mailing Address - Fax:213-380-2419
Practice Address - Street 1:1105 S. EUCLID ST. SUITE E
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832
Practice Address - Country:US
Practice Address - Phone:714-738-0304
Practice Address - Fax:213-380-2419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-07
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40048122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA40048OtherHEALTHY FAMILY
CAB40048Medicaid