MEDICARE: DR. KYEONG MAN PARK DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0401411191	VA

General Provider Information

NPI Number	:	1073523387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYEONG MAN PARK DDS

Provider Business Mailing Address
First Line	:	762 INDEPENDENCE BLVD STE 500
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-6242
Country	:	US
Telephone Number	:	757-272-5437
Fax Number	:	757-210-4210

Provider Business Practice Location Address
First Line	:	762 INDEPENDENCE BLVD STE 500
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-6242
Country	:	US
Telephone Number	:	757-272-5437
Fax Number	:	757-838-9150

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	10/19/2023

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