Provider Demographics
NPI:1811661648
Name:PARK, CHAN HEE (DDS)
Entity type:Individual
Prefix:DR
First Name:CHAN HEE
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 1:1812 LINDA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-1149
Mailing Address - Country:US
Mailing Address - Phone:213-703-3481
Mailing Address - Fax:
Practice Address - Street 1:1812 LINDA VISTA AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-1149
Practice Address - Country:US
Practice Address - Phone:213-703-3481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1064261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice