Provider Demographics
NPI:1598932212
Name:PARK, CHARLIE
Entity Type:Individual
Prefix:DR
First Name:CHARLIE
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 COMMERCE DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:FT WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19034-2714
Mailing Address - Country:US
Mailing Address - Phone:267-460-4254
Mailing Address - Fax:
Practice Address - Street 1:401 COMMERCE DR
Practice Address - Street 2:SUITE 108
Practice Address - City:FT WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:19034-2714
Practice Address - Country:US
Practice Address - Phone:267-460-4254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PADS038502122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program