Provider Demographics
NPI:1104363019
Name:PARK, HOSAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:HOSAN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2144 9TH AVE W
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98119-2843
Mailing Address - Country:US
Mailing Address - Phone:917-226-7669
Mailing Address - Fax:
Practice Address - Street 1:25610 104TH AVE SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7610
Practice Address - Country:US
Practice Address - Phone:253-850-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2018-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0314201223P0300X
WADE607220331223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics