Provider Demographics
NPI:1235701475
Name:PARK, JESSICA (DDS)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
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 1:4307 COTTONWOOD CREEK LN
Mailing Address - Street 2:
Mailing Address - City:MANVEL
Mailing Address - State:TX
Mailing Address - Zip Code:77578-2035
Mailing Address - Country:US
Mailing Address - Phone:626-827-2455
Mailing Address - Fax:
Practice Address - Street 1:925 N ELDRIDGE PKWY STE 1N353
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079-2703
Practice Address - Country:US
Practice Address - Phone:281-643-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-16
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37436122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist