Healthcare Provider Details

I. General information

NPI: 1477145449
Provider Name (Legal Business Name): PARK XIONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 BROADWAY ST NE
MINNEAPOLIS MN
55413-2164
US

IV. Provider business mailing address

2590 49TH ST E
INVER GROVE HEIGHTS MN
55076-1158
US

V. Phone/Fax

Practice location:
  • Phone: 612-746-1530
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT135
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: