Provider Demographics
NPI:1073523387
Name:PARK, KYEONG MAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYEONG
Middle Name:MAN
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:CHRIS
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:762 INDEPENDENCE BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6242
Mailing Address - Country:US
Mailing Address - Phone:757-272-5437
Mailing Address - Fax:757-210-4210
Practice Address - Street 1:762 INDEPENDENCE BLVD STE 500
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6242
Practice Address - Country:US
Practice Address - Phone:757-272-5437
Practice Address - Fax:757-838-9150
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014111911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice