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General NPI Number Information
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NPI Number | 1730433830
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Entity Type | Individual
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Provider Name | KONY PARK D.M.D
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Gender | Male
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Dates
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Enumeration Date | 10/29/2012
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Last Update Date | 01/16/2024
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Provider Practice Location Address
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Address Line | 4913 MORELAND DR STE 103
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City | GEORGETOWN
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State | TX
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Zip | 78633-5509
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Country | US
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Telephone | 512-275-4222
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Fax |
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Provider Business Mailing Address
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Address Line | 30102 DIAMOND DOVE TRL
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City | GEORGETOWN
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State | TX
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Zip | 78628-3724
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Country | US
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Telephone | 253-503-9655
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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 | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 36695
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License Number State | TX
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