Provider Demographics
NPI:1912318908
Name:PARK, JASON
Entity Type:Individual
Prefix:MR
First Name:JASON
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:#701-2233 ALLISON ROAD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:BRITISH COLUMBIA
Mailing Address - Zip Code:V6T 1T7
Mailing Address - Country:CA
Mailing Address - Phone:604-764-7919
Mailing Address - Fax:
Practice Address - Street 1:HOSPITAL DENTISTRY WESTCHESTER HL
Practice Address - Street 2:RM 151
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8711
Practice Address - Country:US
Practice Address - Phone:631-444-2557
Practice Address - Fax:631-444-6013
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program