Provider Demographics
NPI:1043529456
Name:PARK, HYUNSEO
Entity Type:Individual
Prefix:
First Name:HYUNSEO
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 SPYGLASS DR
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-3164
Mailing Address - Country:US
Mailing Address - Phone:415-728-5003
Mailing Address - Fax:
Practice Address - Street 1:3329 TURNER PLZ
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-8709
Practice Address - Country:US
Practice Address - Phone:415-728-5003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-03
Last Update Date:2010-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26001122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist