MEDICARE: DR. CHIN S PARK DMD

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	DN014213	GA
2	1223G0001X	General Practice Dentistry	FP2954899	GA

General Provider Information

NPI Number	:	1508139890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHIN S PARK DMD

Provider Business Mailing Address
First Line	:	2415 W PARK PLACE BLVD
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30087-3566
Country	:	US
Telephone Number	:	770-879-1200
Fax Number	:	770-413-1821

Provider Business Practice Location Address
First Line	:	2415 W PARK PLACE BLVD
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30087-3566
Country	:	US
Telephone Number	:	770-879-1200
Fax Number	:	770-413-1821

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

Provider Enumeration Date	:	02/16/2012
Last Update Date	:	09/09/2024

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