Provider Demographics
NPI:1740482694
Name:OOLI ORTHODONTICS - AZ, PHX, P.C.
Entity type:Organization
Organization Name:OOLI ORTHODONTICS - AZ, PHX, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WON-WOO
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:480-777-7759
Mailing Address - Street 1:6200 S MCCLINTOCK DR
Mailing Address - Street 2:SUITE #4
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-3268
Mailing Address - Country:US
Mailing Address - Phone:480-777-7759
Mailing Address - Fax:480-777-7120
Practice Address - Street 1:1701 W GLENDALE AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-9701
Practice Address - Country:US
Practice Address - Phone:480-777-7759
Practice Address - Fax:480-777-7120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ65421223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty