Active NPI
Yong Tae Park
- Endodontics
- Elk Grove, CA
National Provider Identifier
1952969354
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Endodontics
- License
- DDS103561
- Practice address
- 9184 E Stockton Blvd Ste a
Elk Grove, CA 95624-9510 - Phone
- (201) 835-6802
- NPI assigned
- May 31, 2019
- 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 |
|---|---|---|---|---|
| Endodontics | 1223E0200X | DDS103561 | CA | Primary |
Addresses
Primary practice location
9184 E Stockton Blvd Ste a
Elk Grove, CA 95624-9510
Mailing address
9184 E Stockton Blvd Ste a
Elk Grove, CA 95624-9510
Phone (201) 835-6802
Medicare participation
Medicare enrollment files- 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
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20250905001314 | CA | Order and Referring Only - Dentist | 1456853886 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DDS103561 | CA | MD | Endodontist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1559260800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1681603200000",
"number": "1952969354",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "9184 E STOCKTON BLVD STE A",
"city": "ELK GROVE",
"state": "CA",
"postal_code": "956249510",
"telephone_number": "201-835-6802"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "9184 E STOCKTON BLVD STE A",
"city": "ELK GROVE",
"state": "CA",
"postal_code": "956249510",
"telephone_number": "201-835-6802"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PARK",
"first_name": "YONG TAE",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2019-05-31",
"last_updated": "2023-04-16",
"certification_date": "2023-04-16",
"status": "A"
},
"taxonomies": [
{
"code": "1223E0200X",
"taxonomy_group": "",
"desc": "Dentist, Endodontics",
"state": "CA",
"license": "DDS103561",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Elk Grove, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 16, 2023; 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.