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General NPI Number Information
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NPI Number | 1235403700
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Entity Type | Organization
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Legal Business Name | PARK DENTAL GROUP
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Dates
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Enumeration Date | 03/01/2012
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Last Update Date | 03/01/2012
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Provider Practice Location Address
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Address Line | 256 N HAMMOND DR
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City | MONROE
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State | GA
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Zip | 30655-2475
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Country | US
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Telephone | 770-207-0008
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Fax | 770-207-0033
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Provider Business Mailing Address
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Address Line | 256 N HAMMOND DR
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City | MONROE
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State | GA
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Zip | 30655-2475
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Country | US
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Telephone | 770-207-0008
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Fax | 770-207-0033
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Authorized Official
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Title or Position | GENERAL DENTISTRY
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Name | DR. HYUN W. PARK
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Credential | D.D.S
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Telephone | 770-207-0008
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DN012810
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License Number State | GA
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