Provider Demographics
NPI:1639626450
Name:PARK, AIDAN (DDS)
Entity Type:Individual
Prefix:
First Name:AIDAN
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 1:2050 E ALGONQUIN RD
Mailing Address - Street 2:STE 610
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4144
Mailing Address - Country:US
Mailing Address - Phone:888-988-4066
Mailing Address - Fax:847-496-4850
Practice Address - Street 1:6430 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2948
Practice Address - Country:US
Practice Address - Phone:888-988-4066
Practice Address - Fax:847-496-4850
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001421122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist