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General NPI Number Information
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NPI Number | 1689842379
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Entity Type | Individual
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Provider Name | BRIAN PARK DDS
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Gender | Male
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Dates
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Enumeration Date | 02/14/2008
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Last Update Date | 06/03/2009
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Provider Practice Location Address
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Address Line | 325 MEETING HOUSE LN BLDG #2 SUITE 401
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City | SOUTHAMPTON
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State | NY
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Zip | 11968-5087
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Country | US
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Telephone | 631-283-0352
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Fax |
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Provider Business Mailing Address
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Address Line | 31 MARTIN PL
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City | SYOSSET
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State | NY
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Zip | 11791-6712
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Country | US
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Telephone | 718-926-5398
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 051949
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License Number State | NY
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