Provider Demographics
NPI:1467756411
Name:PARK, NAM HEE AVA (DDS)
Entity type:Individual
Prefix:
First Name:NAM HEE
Middle Name:AVA
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 1:40910 FREMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-4375
Mailing Address - Country:US
Mailing Address - Phone:510-770-8040
Mailing Address - Fax:
Practice Address - Street 1:2060 ABORN RD STE 123
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-1584
Practice Address - Country:US
Practice Address - Phone:408-729-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0104371223G0001X
NY0563931223G0001X
NY056393-11223G0001X
CA1091441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04401850Medicaid
NY331945Medicare Oscar/Certification
NY331943Medicare Oscar/Certification
NY331946Medicare Oscar/Certification
NYG100000410Medicare Oscar/Certification
NY00695941Medicaid
NYW6L111Medicare Oscar/Certification