=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538427786
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUNG PARK DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2012
-----------------------------------------------------
Last Update Date | 05/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6804 43RD AVE FL 1
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-5153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-459-5235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 68-04 43RD AVE 1FL
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-459-5235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 055824
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------