Healthcare Provider Details

I. General information

NPI: 1639535560
Provider Name (Legal Business Name): HYUNJUNG PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2016
Last Update Date: 01/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 CENTRAL AVE NW STE F1
ALBUQUERQUE NM
87105-1669
US

IV. Provider business mailing address

350 N CLARK ST FL 6 DENTAL DREAMS LLC C/O JULIETTE BOYCE
CHICAGO IL
60654-4712
US

V. Phone/Fax

Practice location:
  • Phone: 505-843-7172
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4432
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: