Tina Keun Nan Park, D.D.S., M.S.

Primary specialty

Orthodontics and Dentofacial Orthopedics DentistryTaxonomy code 1223X0400X

License

63253 Issued in CA

Practice address

11011 Meridian Ave N Ste 104
Seattle, WA 98133-8967

Phone

(855) 433-6825

NPI assigned

Apr 14, 2016

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in WA

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

Credentials

Master of Science

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Willamette Dental Group, P.C.

  • Dentist
  • Seattle, WA
  • NPI 1033034491
  NPD (past)
• Willamette Dental Group, P.C.

  • Dentist
  • Bellevue, WA
  • NPI 1588589949
  NPD (past)

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

{
    "created_epoch": "1460592000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1731974400000",
    "number": "1407200694",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6950 NE CAMPUS WAY",
            "city": "HILLSBORO",
            "state": "OR",
            "postal_code": "971245611",
            "telephone_number": "855-433-6825"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11011 MERIDIAN AVE N STE 104",
            "city": "SEATTLE",
            "state": "WA",
            "postal_code": "981338967",
            "telephone_number": "855-433-6825"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "626 120th Ave NE Ste B210",
            "address_purpose": "LOCATION",
            "city": "Bellevue",
            "state": "WA",
            "postal_code": "980053038",
            "country_code": "US",
            "telephone_number": "855-433-6825",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "3216 Norton Ave",
            "address_purpose": "LOCATION",
            "city": "Everett",
            "state": "WA",
            "postal_code": "982014290",
            "country_code": "US",
            "telephone_number": "855-433-6825",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PARK",
        "first_name": "TINA",
        "middle_name": "KEUN NAN",
        "credential": "D.D.S., M.S.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2016-04-14",
        "last_updated": "2024-11-19",
        "certification_date": "2024-11-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223X0400X",
            "taxonomy_group": "",
            "desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
            "state": "CA",
            "license": "63253",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Stephen B Park, D.M.D.
• Suejin Park, PHARM D
• Sung Yoon Park, MD, PHD
• Sunghye Park
• Timothy Park
• Woo Jin Park, D.M.D.
• Ye Eun Park
• Yeojung Park
• Nina Yael Parker-Cohen, PH.D.
• Aaron Parker, MSW

• Orthodontics and Dentofacial Orthopedics Dentistry in Seattle, WA
• Providers in Seattle, WA by specialty
• Orthodontics and Dentofacial Orthopedics Dentistry in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 19, 2024; 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.