Provider Demographics
NPI:1225640394
Name:KINGS PARK DENTAL, LLC
Entity Type:Organization
Organization Name:KINGS PARK DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:YI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:571-407-5981
Mailing Address - Street 1:8942 BURKE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22151-1004
Mailing Address - Country:US
Mailing Address - Phone:571-407-5981
Mailing Address - Fax:571-407-7238
Practice Address - Street 1:8942 BURKE LAKE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151-1004
Practice Address - Country:US
Practice Address - Phone:571-407-5981
Practice Address - Fax:571-407-7238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental