Jonathan J Park, D.M.D.,M.D.
Dentist, Oral and Maxillofacial Surgery in Fairfax, VA. Individual provider (NPI-1).
NPI number1114940905
StatusActive
Last updated in NPPESJul 8, 2007
Details
- NPI
- 1114940905
- Entity type
- Individual (NPI-1)
- Name
- Jonathan J Park
- Credential
- D.M.D.,M.D.
- Sex
- Male
- Sole proprietor
- No
- Enumeration date
- Jul 25, 2006
- Last updated
- Jul 8, 2007
Medicare and OIG
- Medicare enrolled (PECOS)
- Not in the Medicare enrollment file
- Can order and refer
- Part B Yes · DME Yes · Home health Yes · Power mobility No · Hospice Yes
- Medicare opt-out
- Apr 1, 2012 to Apr 1, 2028
- OIG exclusion list
- This NPI is not listed
CMS and OIG files of November 2026. PECOS lookup · OIG exclusion check
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 1223S0112X | Dentist, Oral and Maxillofacial Surgery | 0101221324 | VA | Yes |
Practice location
10530 Rosehaven StSuite 111
Fairfax, VA 22030-2840
Phone 703-385-5777 · Fax 703-591-5386
Mailing address
10530 Rosehaven StSuite 111
Fairfax, VA 22030-2840
Phone 703-385-5777 · Fax 703-591-5386
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This page shows exactly what the provider filed with NPPES. Only the provider (or their surrogate) can change it, by signing in to NPPES. Our page updates within a day of their change. See how to update NPI information.
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