Basic Information
| Provider Information | |||||||||
| NPI: | 1639532104 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 166 CHAMPIONS RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | SOUTHERN PINES | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283873084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318486983 | ||||||||
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| Practice Location | |||||||||
| Address1: | WOMACK ARMY MEDICAL CENTER | ||||||||
| Address2: | |||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283100001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109076000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2016 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.