Provider Demographics
NPI:1467756411
Name:PARK, NAM HEE AVA (DDS)
Entity Type:Individual
Prefix:
First Name:NAM HEE
Middle Name:AVA
Last Name:PARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-5901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:131-72 40TH ROAD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354
Practice Address - Country:US
Practice Address - Phone:718-587-1111
Practice Address - Fax:718-886-3903
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0563931223G0001X
CT0104371223G0001X
NY056393-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04401850Medicaid
NY331945Medicare Oscar/Certification
NY331943Medicare Oscar/Certification
NY331946Medicare Oscar/Certification
NYG100000410Medicare Oscar/Certification
NY00695941Medicaid
NYW6L111Medicare Oscar/Certification