Healthcare Provider Details

I. General information

NPI: 1538193966
Provider Name (Legal Business Name): JOHN C. PARK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 W MAIN ST SUITE 210
HOPKINTON MA
01748-1684
US

IV. Provider business mailing address

484 WINTER ST
HOLLISTON MA
01746-1100
US

V. Phone/Fax

Practice location:
  • Phone: 508-435-5455
  • Fax: 508-435-9499
Mailing address:
  • Phone: 508-429-2098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number20976
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: