Provider Demographics
NPI:1770210254
Name:PARK, JUN SANG
Entity type:Individual
Prefix:
First Name:JUN SANG
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 BLANCHE ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-3944
Mailing Address - Country:US
Mailing Address - Phone:209-518-2095
Mailing Address - Fax:
Practice Address - Street 1:4220 W 3RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-3450
Practice Address - Country:US
Practice Address - Phone:209-518-2095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1075131223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADDS107513OtherDENTAL BOARD OF CALIFORNIA