Provider Demographics
NPI:1235403700
Name:PARK DENTAL GROUP
Entity Type:Organization
Organization Name:PARK DENTAL GROUP
Other - Org Name:MONROE SMILE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL DENTISTRY
Authorized Official - Prefix:DR
Authorized Official - First Name:HYUN
Authorized Official - Middle Name:W
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-207-0008
Mailing Address - Street 1:256 N HAMMOND DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-2475
Mailing Address - Country:US
Mailing Address - Phone:770-207-0008
Mailing Address - Fax:770-207-0033
Practice Address - Street 1:256 N HAMMOND DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-2475
Practice Address - Country:US
Practice Address - Phone:770-207-0008
Practice Address - Fax:770-207-0033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012810261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental