Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 102883 | CA |
NPI | 1003394313 |
---|---|
Provider Name | Dr. Jonggoo Park |
First Address | Murrieta, CA 92562-5791 |
Second Address | Murrieta, CA 92562-5791 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/07/2018 |
Last Update Date | 30/07/2018 |