Provider Demographics
NPI:1629610571
Name:PARK, SOON HO (DDS)
Entity Type:Individual
Prefix:
First Name:SOON HO
Middle Name:
Last Name:PARK
Suffix:
Gender:M
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:PO BOX 5027 CHRB
Mailing Address - Street 2:
Mailing Address - City:SAIPAN
Mailing Address - State:MP
Mailing Address - Zip Code:96950
Mailing Address - Country:US
Mailing Address - Phone:670-588-8533
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 5027 CHRB
Practice Address - Street 2:
Practice Address - City:SAIPAN
Practice Address - State:MP
Practice Address - Zip Code:96950
Practice Address - Country:US
Practice Address - Phone:670-588-8533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MP01811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice