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General NPI Number Information
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NPI Number | 1578851002
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Entity Type | Organization
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Legal Business Name | YOUNG C. PARK, DDS., PC
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Dates
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Enumeration Date | 07/19/2011
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Last Update Date | 06/19/2022
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Provider Practice Location Address
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Address Line | 6625 WILLIAMSON RD
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City | ROANOKE
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State | VA
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Zip | 24019-4631
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Country | US
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Telephone | 540-563-9398
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Fax |
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Provider Business Mailing Address
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Address Line | 6625 WILLIAMSON RD
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City | ROANOKE
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State | VA
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Zip | 24019-4631
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Country | US
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Telephone | 540-563-9398
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | YOUNG CHUL PARK
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Credential | DDS
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Telephone | 540-563-9398
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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 | 0401412589
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License Number State | VA
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