Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | DDS100104 | CA |
NPI | 1013365881 |
---|---|
Provider Name | Dr. Jessica Yoon Kyung Pack |
First Address | Los Angeles, CA 90017-1974 |
Second Address | Los Angeles, CA 90017-1974 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/06/2016 |
Last Update Date | 02/06/2016 |