Provider Demographics
NPI:1124409560
Name:PARK, ZIVIN
Entity Type:Individual
Prefix:
First Name:ZIVIN
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:PMB 121-10001
Mailing Address - Street 2:
Mailing Address - City:SAIPAN
Mailing Address - State:MP
Mailing Address - Zip Code:96950
Mailing Address - Country:US
Mailing Address - Phone:670-235-2378
Mailing Address - Fax:
Practice Address - Street 1:5200 S WESTNEDGE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002
Practice Address - Country:US
Practice Address - Phone:269-382-6656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021641122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist