Provider Demographics
NPI:1639557390
Name:D J PARK PC
Entity Type:Organization
Organization Name:D J PARK PC
Other - Org Name:ASPEN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONG
Authorized Official - Middle Name:JIN
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-454-6000
Mailing Address - Street 1:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-3189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:490-19 SOUTH BROAD STREET
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450
Practice Address - Country:US
Practice Address - Phone:203-237-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty