Provider Demographics
NPI:1821510314
Name:PARK, SO YOUNG (DDS)
Entity Type:Individual
Prefix:DR
First Name:SO YOUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 3RD AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2409
Mailing Address - Country:US
Mailing Address - Phone:734-255-9641
Mailing Address - Fax:
Practice Address - Street 1:100 S 4TH ST
Practice Address - Street 2:UNIT 2
Practice Address - City:ELDRIDGE
Practice Address - State:IA
Practice Address - Zip Code:52748
Practice Address - Country:US
Practice Address - Phone:563-285-5600
Practice Address - Fax:563-285-5601
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-094241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice