Healthcare Provider Details

I. General information

NPI: 1023148749
Provider Name (Legal Business Name): YEONSOO PARK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 402 AE 09180
APO AE
09180
US

IV. Provider business mailing address

CMR 402 APO, AE 09180-0402
APO AE
09180
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-7860
  • Fax:
Mailing address:
  • Phone: 63-719-4645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10410
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: