Healthcare Provider Details

I. General information

NPI: 1316477524
Provider Name (Legal Business Name): RYAN PARK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 HURLEY AVENUE
ROCKVILLE MD
20850
US

IV. Provider business mailing address

13975 CONNECTICUT AVE STE 208
SILVER SPRING MD
20906-2921
US

V. Phone/Fax

Practice location:
  • Phone: 224-500-1814
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number019.031142
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number17982
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.031142
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: