Healthcare Provider Details

I. General information

NPI: 1225486947
Provider Name (Legal Business Name): SONG YONG PARK D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2016
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 BENWOOD AVE
BUFFALO NY
14214-1761
US

IV. Provider business mailing address

34 BENWOOD AVE
BUFFALO NY
14214-1761
US

V. Phone/Fax

Practice location:
  • Phone: 716-986-9199
  • Fax: 716-342-2340
Mailing address:
  • Phone: 716-986-9199
  • Fax: 716-342-2340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number059200
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: