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General NPI Number Information
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NPI Number | 1144452830
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Entity Type | Individual
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Provider Name | ERIC PARK D.M.D
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Gender | Male
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Dates
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Enumeration Date | 08/14/2009
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Last Update Date | 11/05/2010
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Provider Practice Location Address
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Address Line | 4935 STEWART MILL RD SUITE 200
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City | DOUGLASVILLE
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State | GA
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Zip | 30135-6733
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Country | US
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Telephone | 770-627-3042
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Fax | 770-627-3243
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Provider Business Mailing Address
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Address Line | 97 EAGLE ROCK DR
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City | ACWORTH
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State | GA
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Zip | 30101-1916
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 012946
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License Number State | GA
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