John Joontae Park, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

D10627 Issued in OR

Practice address

2100 NE Broadway St Ste 205
Portland, OR 97232-1500

Phone

(503) 284-2893

Fax

(503) 287-2016

NPI assigned

May 19, 2016

Sex

Male

Sole proprietor

No

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 OR

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": "1463616000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1729468800000",
    "number": "1558718437",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2100 NE BROADWAY ST STE 205",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972321500",
            "telephone_number": "503-284-2893",
            "fax_number": "503-287-2016"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2100 NE BROADWAY ST STE 205",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972321500",
            "telephone_number": "503-284-2893",
            "fax_number": "503-287-2016"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PARK",
        "first_name": "JOHN",
        "middle_name": "JOONTAE",
        "credential": "D.D.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2016-05-19",
        "last_updated": "2024-10-21",
        "certification_date": "2024-10-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "OR",
            "license": "D10627",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Eun Park
• Eun Hyun Park, DDS, PHD
• Hyun Jeong Park
• Jessica L. Park, PHARM.D.
• Jin S Park, MD
• Kaitlin Elizabeth Park
• Katherine Park
• Kristine Jayoung Park, DO
• Laura Jo Park, L.M.F.T.
• Lindsay Meredith Park

• General Practice Dentistry in Portland, OR
• Providers in Portland, OR by specialty
• General Practice Dentistry in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 21, 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.