Provider Demographics
NPI:1063026235
Name:PARK, SANGHYUN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SANGHYUN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:SCOTT
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1103 STEWART AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4886
Mailing Address - Country:US
Mailing Address - Phone:516-222-1822
Mailing Address - Fax:
Practice Address - Street 1:1103 STEWART AVE STE 104
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4886
Practice Address - Country:US
Practice Address - Phone:516-222-1822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0612921223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics