Provider Demographics
NPI:1619440922
Name:PARK, JOO
Entity type:Individual
Prefix:
First Name:JOO
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:BRIAN D. ALLGOOD ARMY COMMUNITY HOSPITAL (BDAACH)
Mailing Address - Street 2:UNIT #15245; BLDG 3031
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:92671-5245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BRIAN D. ALLGOOD ARMY COMMUNITY HOSPITAL (BDAACH)
Practice Address - Street 2:UNIT #15245; BLDG 3031
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96271-5245
Practice Address - Country:US
Practice Address - Phone:315-737-9013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401416263122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist