Basic Information
Provider Information | |||||||||
NPI: | 1699916585 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARK | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.D.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 205 E UNIVERSITY AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | GEORGETOWN | ||||||||
State: | TX | ||||||||
PostalCode: | 786266821 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8778005722 | ||||||||
FaxNumber: | 5128692940 | ||||||||
Practice Location | |||||||||
Address1: | 2411 WILLIAMS DR STE 111 | ||||||||
Address2: |   | ||||||||
City: | GEORGETOWN | ||||||||
State: | TX | ||||||||
PostalCode: | 786283268 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8778005722 | ||||||||
FaxNumber: | 5128641447 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/23/2009 | ||||||||
LastUpdateDate: | 04/24/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DE60056279 | WA | N |   | Dental Providers | Dentist |   | 1223G0001X | 28680 | TX | Y |   | Dental Providers | Dentist | General Practice |
No ID Information.