MEDICARE: DR. HAE DUK PARK D.M.D.

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	1223G0001X	General Practice Dentistry	0401410598	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0401410598	OTHER	VA	VA DENTAL LIC#
2	1745319	OTHER	PA	UNITED CONCORDIA INS.ID
3	178830	OTHER	VA	ANTHEM BCBS ID #

General Provider Information

NPI Number	:	1174607832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HAE DUK PARK D.M.D.

Provider Business Mailing Address
First Line	:	8714 SUDLEY RD
Second Line	:
City	:	MANASSAS
State	:	VA
Zip	:	20110-4405
Country	:	US
Telephone Number	:	703-368-8166
Fax Number	:	703-368-8624

Provider Business Practice Location Address
First Line	:	8714 SUDLEY RD
Second Line	:
City	:	MANASSAS
State	:	VA
Zip	:	20110-4405
Country	:	US
Telephone Number	:	703-368-8166
Fax Number	:	703-368-8624

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

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	03/07/2023

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