Provider Demographics
NPI:1124381363
Name:PARKS, KEVIN JARED (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JARED
Last Name:PARKS
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 1:4501 E SNIDER DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7604
Mailing Address - Country:US
Mailing Address - Phone:907-376-8400
Mailing Address - Fax:
Practice Address - Street 1:4501 E SNIDER DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7604
Practice Address - Country:US
Practice Address - Phone:907-376-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK14191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice