Provider Demographics
NPI:1689842379
Name:PARK, BRIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
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 1:31 MARTIN PL
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-6712
Mailing Address - Country:US
Mailing Address - Phone:718-926-5398
Mailing Address - Fax:
Practice Address - Street 1:325 MEETING HOUSE LN
Practice Address - Street 2:BLDG #2 SUITE 401
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5087
Practice Address - Country:US
Practice Address - Phone:631-283-0352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-14
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0519491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice