Provider Demographics
NPI:1609258722
Name:JUN PARK D.D.S.,P.A.
Entity type:Organization
Organization Name:JUN PARK D.D.S.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUN
Authorized Official - Middle Name:Y
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-321-6120
Mailing Address - Street 1:1205 YORK RD
Mailing Address - Street 2:SUITE 25A
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-6210
Mailing Address - Country:US
Mailing Address - Phone:410-321-6120
Mailing Address - Fax:410-321-6121
Practice Address - Street 1:1205 YORK RD
Practice Address - Street 2:SUITE 25A
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6210
Practice Address - Country:US
Practice Address - Phone:410-321-6120
Practice Address - Fax:410-321-6121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD134011223G0001X
MD156321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1548443831Medicaid