Provider Demographics
NPI:1033624655
Name:PARK, MINERVA C (DDS)
Entity Type:Individual
Prefix:DR
First Name:MINERVA
Middle Name:C
Last Name:PARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 CUSHING CIR APT 117
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5010
Mailing Address - Country:US
Mailing Address - Phone:443-857-4207
Mailing Address - Fax:
Practice Address - Street 1:555 WABASHA ST N STE 250
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1673
Practice Address - Country:US
Practice Address - Phone:651-292-9331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND139071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice