Healthcare Provider Details

I. General information

NPI: 1710545637
Provider Name (Legal Business Name): SI-EUN PARK DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 DUKE ST STE 150
ALEXANDRIA VA
22314-6122
US

IV. Provider business mailing address

4060 GATEWAY DR APT 5507
FAIRFAX VA
22030-5062
US

V. Phone/Fax

Practice location:
  • Phone: 703-276-1110
  • Fax:
Mailing address:
  • Phone: 330-631-3238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401418414
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: