Provider Demographics
NPI:1669907663
Name:PARK, JUN SUP (DDS)
Entity type:Individual
Prefix:DR
First Name:JUN SUP
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8612 FIRESTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-5243
Mailing Address - Country:US
Mailing Address - Phone:562-382-1528
Mailing Address - Fax:
Practice Address - Street 1:8612 FIRESTONE BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-5243
Practice Address - Country:US
Practice Address - Phone:562-382-1528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022211122300000X
CA107810122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist