Provider Demographics
NPI:1770135774
Name:PARK, JI SOO (DDS)
Entity type:Individual
Prefix:DR
First Name:JI SOO
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4611 PRESTON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-7488
Mailing Address - Country:US
Mailing Address - Phone:469-299-4091
Mailing Address - Fax:
Practice Address - Street 1:4611 PRESTON RD STE 100
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-7488
Practice Address - Country:US
Practice Address - Phone:469-299-4091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX352441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice