Provider Demographics
NPI:1710620414
Name:SMILE PARK DENTAL LLC
Entity Type:Organization
Organization Name:SMILE PARK DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:Y
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:410-721-5000
Mailing Address - Street 1:1702 TRANSPORTATION BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2151
Mailing Address - Country:US
Mailing Address - Phone:410-721-5000
Mailing Address - Fax:
Practice Address - Street 1:1702 TRANSPORTATION BLVD STE F
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2151
Practice Address - Country:US
Practice Address - Phone:410-721-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental