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General NPI Number Information
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NPI Number | 1699041897
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Entity Type | Organization
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Legal Business Name | SUN PARK DDS PC
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Dates
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Enumeration Date | 04/02/2012
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Last Update Date | 04/02/2012
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Provider Practice Location Address
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Address Line | 102 ELDEN ST STE 17
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City | HERNDON
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State | VA
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Zip | 20170-4827
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Country | US
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Telephone | 703-485-9098
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Fax | 703-485-8098
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Provider Business Mailing Address
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Address Line | 102 ELDEN ST STE 17
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City | HERNDON
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State | VA
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Zip | 20170-4827
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Country | US
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Telephone | 703-485-9098
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Fax | 703-485-8098
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SUN PARK
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Credential |
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Telephone | 571-485-9098
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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 | 0401412056
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License Number State | VA
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