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General NPI Number Information
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NPI Number | 1326293614
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Entity Type | Individual
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Provider Name | DR. NAM PARK
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Gender | Male
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Dates
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Enumeration Date | 12/01/2008
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Last Update Date | 12/30/2020
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Provider Practice Location Address
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Address Line | 140 W 69TH ST OFC G1
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City | NEW YORK
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State | NY
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Zip | 10023-5321
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Country | US
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Telephone | 212-466-6984
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Fax |
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Provider Business Mailing Address
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Address Line | 140 W 69TH ST OFC G1
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City | NEW YORK
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State | NY
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Zip | 10023-5321
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Country | US
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Telephone | 212-466-6984
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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 | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 22DI02506200
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 053029
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License Number State | NY
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