Provider Demographics
NPI:1811065238
Name:PARK, JAE HYUN (DMD, PHD)
Entity type:Individual
Prefix:DR
First Name:JAE
Middle Name:HYUN
Last Name:PARK
Suffix:
Gender:M
Credentials:DMD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5519 E BERYL AVE
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-1165
Mailing Address - Country:US
Mailing Address - Phone:480-286-0455
Mailing Address - Fax:
Practice Address - Street 1:3155 W INDIAN SCHOOL RD
Practice Address - Street 2:WESTERN DENTAL ORTHODONTIC OFFICE
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-4035
Practice Address - Country:US
Practice Address - Phone:480-286-0455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ70191223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics