Provider Demographics
NPI:1508208547
Name:PARK, AH REUM
Entity Type:Individual
Prefix:
First Name:AH REUM
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 KILEY PKWY
Mailing Address - Street 2:#1707
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89436-4076
Mailing Address - Country:US
Mailing Address - Phone:480-414-0660
Mailing Address - Fax:
Practice Address - Street 1:5015 PYRAMID WAY
Practice Address - Street 2:#113
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89436-7746
Practice Address - Country:US
Practice Address - Phone:775-424-3000
Practice Address - Fax:775-424-3005
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV64531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice