Healthcare Provider Details

I. General information

NPI: 1629242946
Provider Name (Legal Business Name): SANG HOON PARK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W BALTIMORE ST ROOM 4203
BALTIMORE MD
21201-1510
US

IV. Provider business mailing address

650 W BALTIMORE ST ROOM 4203
BALTIMORE MD
21201-1510
US

V. Phone/Fax

Practice location:
  • Phone: 443-827-9248
  • Fax:
Mailing address:
  • Phone: 443-827-9248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDEN1000707
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number13704
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: