Provider Demographics
NPI:1790848141
Name:PARK, DONGWOO (DDS DMD MSD)
Entity Type:Individual
Prefix:DR
First Name:DONGWOO
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS DMD MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6C N COMMONS
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:MA
Mailing Address - Zip Code:01773-1116
Mailing Address - Country:US
Mailing Address - Phone:781-504-7275
Mailing Address - Fax:
Practice Address - Street 1:1 KNEELAND ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1527
Practice Address - Country:US
Practice Address - Phone:617-636-6556
Practice Address - Fax:617-636-6583
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2015-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19033122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist