=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144422239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | W.W. PARK, D.M.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2007
-----------------------------------------------------
Last Update Date | 06/05/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1333 W CHELTENHAM AVE SUITE #202
-----------------------------------------------------
City | ELKINS PARK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19027-3140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-782-8330
-----------------------------------------------------
Fax | 215-782-3266
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 W BROOKHAVEN RD
-----------------------------------------------------
City | WALLINGFORD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19086-6339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-782-8330
-----------------------------------------------------
Fax | 215-782-3266
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WON-WOO PARK
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 215-782-8330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DS030803L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------