Provider Demographics
NPI:1750964938
Name:PARK, HANSEUL (DDS)
Entity type:Individual
Prefix:DR
First Name:HANSEUL
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 1:2513 TIFFANY PL
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-1527
Mailing Address - Country:US
Mailing Address - Phone:925-872-9499
Mailing Address - Fax:
Practice Address - Street 1:2288 DANIELS ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-6706
Practice Address - Country:US
Practice Address - Phone:209-456-5610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61138583122300000X
CA1061501223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist