Provider Demographics
NPI:1982952198
Name:PARK, OLIVIA JIN-YOUNG (DDS)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:JIN-YOUNG
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 1:1110 E LERDO HWY # 200
Mailing Address - Street 2:
Mailing Address - City:SHAFTER
Mailing Address - State:CA
Mailing Address - Zip Code:93263-9415
Mailing Address - Country:US
Mailing Address - Phone:661-746-6989
Mailing Address - Fax:
Practice Address - Street 1:1110 E LERDO HWY # 200
Practice Address - Street 2:
Practice Address - City:SHAFTER
Practice Address - State:CA
Practice Address - Zip Code:93263-9415
Practice Address - Country:US
Practice Address - Phone:661-746-6989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61769122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA61769OtherCALIFORNIA DENTAL BOARD