Provider Demographics
NPI:1952969354
Name:PARK, YONG TAE
Entity Type:Individual
Prefix:
First Name:YONG TAE
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 1:9184 E STOCKTON BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-9510
Mailing Address - Country:US
Mailing Address - Phone:201-835-6802
Mailing Address - Fax:
Practice Address - Street 1:9184 E STOCKTON BLVD STE A
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-9510
Practice Address - Country:US
Practice Address - Phone:201-835-6802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2023-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1035611223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics