Provider Demographics
NPI:1982824801
Name:PARK, JEEYEOUN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEEYEOUN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3775 VENTURE DR STE B101
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5219
Mailing Address - Country:US
Mailing Address - Phone:404-376-7232
Mailing Address - Fax:
Practice Address - Street 1:2855 LAWRENCEVILLE SUWANEE RD STE 360
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-3596
Practice Address - Country:US
Practice Address - Phone:678-482-2197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0149211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice