Provider Demographics
NPI:1871602722
Name:PARK, GRACE EUNKYOUNG (DMD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:EUNKYOUNG
Last Name:PARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 SW HIGHLAND DR
Mailing Address - Street 2:#A
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-6353
Mailing Address - Country:US
Mailing Address - Phone:503-492-7798
Mailing Address - Fax:503-492-9020
Practice Address - Street 1:1024 SW HIGHLAND DR
Practice Address - Street 2:#A
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-6353
Practice Address - Country:US
Practice Address - Phone:503-492-7798
Practice Address - Fax:503-492-9020
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6881122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist