Healthcare Provider Details

I. General information

NPI: 1760933899
Provider Name (Legal Business Name): SARAH PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12826 SE 40TH LN STE 201
BELLEVUE WA
98006-4276
US

IV. Provider business mailing address

4557 11TH AVE NE APT C238
SEATTLE WA
98105-0002
US

V. Phone/Fax

Practice location:
  • Phone: 425-641-5303
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberD1 60580186
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE61295550
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: