Provider Demographics
NPI:1174903660
Name:PARK, JONG HOON (DMD)
Entity type:Individual
Prefix:DR
First Name:JONG HOON
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 NOUVELLE WAY UNIT N147
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-1599
Mailing Address - Country:US
Mailing Address - Phone:714-757-2525
Mailing Address - Fax:
Practice Address - Street 1:19 HIGH ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MA
Practice Address - Zip Code:01510-2906
Practice Address - Country:US
Practice Address - Phone:978-365-2463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN03363122300000X
MADN18568941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist