MEDICARE: MYUNG PARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	019.030083	IL

General Provider Information

NPI Number	:	1134527047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYUNG PARK

Provider Business Mailing Address
First Line	:	7770 SIGHTSEEING RD
Second Line	:	DENCOM
City	:	FORT BENNING
State	:	GA
Zip	:	31905-3764
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7770 SIGHTSEEING RD
Second Line	:	DENCOM
City	:	FORT BENNING
State	:	GA
Zip	:	31905-3764
Country	:	US
Telephone Number	:	706-544-2118
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2014
Last Update Date	:	12/09/2014

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Directions to “ MYUNG PARK ” Practice Location

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