Healthcare Provider Details

I. General information

NPI: 1992145445
Provider Name (Legal Business Name): HAN ICK PARK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 N CHARLES ST
BALTIMORE MD
21201-4372
US

IV. Provider business mailing address

5501 OLD YORK RD
PHILADELPHIA PA
19141-3018
US

V. Phone/Fax

Practice location:
  • Phone: 410-685-0002
  • Fax: 410-244-5001
Mailing address:
  • Phone: 215-456-7104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD16180
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: