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General NPI Number Information
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NPI Number | 1770770786
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Entity Type | Individual
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Provider Name | SI-WOON PARK DDS
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Gender | Male
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Dates
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Enumeration Date | 10/03/2007
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Last Update Date | 10/03/2007
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Provider Practice Location Address
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Address Line | 8320 OLD COURTHOUSE RD SUITE 402
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City | VIENNA
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State | VA
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Zip | 22182-3831
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Country | US
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Telephone | 703-356-3970
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Fax | 703-356-3971
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Provider Business Mailing Address
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Address Line | 8320 OLD COURTHOUSE RD SUITE 402
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City | VIENNA
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State | VA
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Zip | 22182-3831
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Country | US
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Telephone | 703-356-3970
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Fax | 703-356-3971
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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 | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 0401410858
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License Number State | VA
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