Provider Demographics
NPI:1659439776
Name:PARK, MICHAEL ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALLEN
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 1:541 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-5536
Mailing Address - Country:US
Mailing Address - Phone:303-776-3030
Mailing Address - Fax:303-776-0312
Practice Address - Street 1:541 MAIN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5536
Practice Address - Country:US
Practice Address - Phone:303-776-3030
Practice Address - Fax:303-776-0312
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO82041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice