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General NPI Number Information
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NPI Number | 1861494791
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Entity Type | Individual
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Provider Name | IAN ANTHONY PARK DDS
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Gender | Male
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Dates
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Enumeration Date | 08/11/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 17705 HUTCHINS DR SUITE 209
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City | MINNETONKA
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State | MN
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Zip | 55345-4145
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Country | US
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Telephone | 925-474-8114
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Fax | 952-474-5195
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Provider Business Mailing Address
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Address Line | 17705 HUTCHINS DR SUITE 209
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City | MINNETONKA
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State | MN
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Zip | 55345-4145
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Country | US
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Telephone | 925-474-8114
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Fax | 952-474-5195
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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 | 9986
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License Number State | MN
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