Healthcare Provider Details

I. General information

NPI: 1851943674
Provider Name (Legal Business Name): HYUNKYU PARK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2019
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22201 MOROSS RD STE 155
DETROIT MI
48236-2152
US

IV. Provider business mailing address

22201 MOROSS RD STE 155
DETROIT MI
48236-2152
US

V. Phone/Fax

Practice location:
  • Phone: 313-499-4775
  • Fax:
Mailing address:
  • Phone: 313-499-4775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901601710
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30.026852
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD13889
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: