Renee Yoosun Park, DDS

Primary specialty

DentistTaxonomy code 122300000X

License

54005 Issued in CA

Practice address

10255 Black Mountain Rd
#P4
San Diego, CA 92126-3866

Phone

(510) 290-2260

NPI assigned

Aug 14, 2006

Last updated

Apr 22, 2014By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1155513600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1398124800000",
    "number": "1073526794",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10255 BLACK MOUNTAIN RD",
            "address_2": "#P4",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921263866",
            "telephone_number": "510-290-2260"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10255 BLACK MOUNTAIN RD",
            "address_2": "#P4",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921263866",
            "telephone_number": "510-290-2260"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PARK",
        "first_name": "RENEE",
        "middle_name": "YOOSUN",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2006-08-14",
        "last_updated": "2014-04-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "CA",
            "license": "54005",
            "primary": true
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "NY",
            "license": "055807-1",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Nan Williams Park, RN
• Nicole Sinae Park
• Paul Park, PHARMD
• Paula Park, PHARMD, PHD
• Peter Joonsun Park, M.D.
• Ro Jong Park, MD
• Samuel Park, M.D.
• Sara Heejung Park, MD
• Seo Hyun Park
• Sharon Park

• Dentist in San Diego, CA
• Providers in San Diego, CA by specialty
• Dentist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 22, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.