Active NPI
Jae Sung Park, D.M.D.
- General Practice Dentistry
- Rock Hill, SC
National Provider Identifier
1134551716
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- DGD.8288 GD
- Practice address
- 1578 Constitution Blvd
Suite 01
Rock Hill, SC 29732-3543 - Phone
- (803) 366-1456
- Fax
- (803) 324-0117
- NPI assigned
- Aug 6, 2013
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | DGD.8288 GD | SC | Primary |
Addresses
Primary practice location
1578 Constitution Blvd
Suite 01
Rock Hill, SC 29732-3543
Mailing address
1578 Constitution Blvd
Suite 01
Rock Hill, SC 29732-3543
Phone (803) 366-1456
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| ZX8288 | Medicaid | SC |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in SC
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160902001276 | SC | Order and Referring Only - Oral Surgery | 6406142207 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DGD.8288 GD | SC | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1375747200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1608768000000",
"number": "1134551716",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1578 CONSTITUTION BLVD",
"address_2": "SUITE 01",
"city": "ROCK HILL",
"state": "SC",
"postal_code": "297323543",
"telephone_number": "803-366-1456"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1578 CONSTITUTION BLVD",
"address_2": "SUITE 01",
"city": "ROCK HILL",
"state": "SC",
"postal_code": "297323543",
"telephone_number": "803-366-1456",
"fax_number": "803-324-0117"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PARK",
"first_name": "JAE SUNG",
"name_prefix": "Dr.",
"credential": "D.M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2013-08-06",
"last_updated": "2020-12-24",
"certification_date": "2020-12-24",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "SC",
"license": "DGD.8288 GD",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "ZX8288",
"state": "SC"
}
],
"endpoints": [],
"other_names": []
}Other providers in Rock Hill, SC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 24, 2020; 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.