Provider Demographics
NPI:1043347677
Name:PARK, LINDA M (DDS)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:M
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:P O BOX 90125
Mailing Address - Street 2:4300 E COURT ST
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509
Mailing Address - Country:US
Mailing Address - Phone:810-742-5140
Mailing Address - Fax:810-742-6650
Practice Address - Street 1:4300 E COURT ST
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1808
Practice Address - Country:US
Practice Address - Phone:810-742-5140
Practice Address - Fax:810-742-6650
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI15447122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist