Paul J Park, DMD

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

0438000506 Issued in VA

Practice address

2601 Clarke Ave
Fort Gregg-Adams, VA 23801

Phone

(804) 734-9747

NPI assigned

Aug 7, 2019

Sex

Male

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

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

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

{
    "created_epoch": "1565136000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1736121600000",
    "number": "1306491261",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2601 CLARKE AVE",
            "city": "FORT GREGG-ADAMS",
            "state": "VA",
            "postal_code": "23801",
            "telephone_number": "804-734-9607"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2601 CLARKE AVE",
            "city": "FORT GREGG-ADAMS",
            "state": "VA",
            "postal_code": "23801",
            "telephone_number": "804-734-9747"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PARK",
        "first_name": "PAUL",
        "middle_name": "J",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2019-08-07",
        "last_updated": "2025-01-06",
        "certification_date": "2025-01-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "VA",
            "license": "0401419061",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "VA",
            "license": "0438000506",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Youngki Noh, DDS
• Kayla Ours, PA-C
• Taneshia Page
• Philip Joseph Pandolfi, DMD
• Marichu M Parham
• Julia Patsell, FNP
• Robyn Marie Reale, PA-C
• Robert Scott Ruehrwein, DDS
• Sage and Blossom Counseling, PLLC
• Tanya J Satterwhite, FNP, PMHNP

• Oral and Maxillofacial Surgery (Dentist) in Fort Gregg-Adams, VA
• Providers in Fort Gregg-Adams, VA by specialty
• Oral and Maxillofacial Surgery (Dentist) in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 6, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.