Provider Demographics
NPI:1205381076
Name:PARK, KA (DMD)
Entity Type:Individual
Prefix:
First Name:KA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1628 W HEBRON PKWY
Mailing Address - Street 2:SUITE 108
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-6528
Mailing Address - Country:US
Mailing Address - Phone:972-492-0002
Mailing Address - Fax:
Practice Address - Street 1:1000 E ELDORADO PKWY #130
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068
Practice Address - Country:US
Practice Address - Phone:469-362-4111
Practice Address - Fax:469-362-4112
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX323051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice