Provider Demographics
NPI:1316835911
Name:PARK, JISOO (DDS)
Entity type:Individual
Prefix:
First Name:JISOO
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 1:63 BAYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-1675
Mailing Address - Country:US
Mailing Address - Phone:213-505-8299
Mailing Address - Fax:
Practice Address - Street 1:63 BAYVIEW DR
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-1675
Practice Address - Country:US
Practice Address - Phone:213-505-8299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-24
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1116211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice