Healthcare Provider Details

I. General information

NPI: 1215283403
Provider Name (Legal Business Name): WOO KWON PARK D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 LIBERTY GROVE RD SUITE 140
ROWLETT TX
75089-3623
US

IV. Provider business mailing address

701 E BLUFF ST APT 7207
FORT WORTH TX
76102-2300
US

V. Phone/Fax

Practice location:
  • Phone: 214-703-0703
  • Fax:
Mailing address:
  • Phone: 213-448-1888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number61550
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number28444
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: