Provider Demographics
NPI:1821513375
Name:LUNA LAND DENTAL, CORP.
Entity Type:Organization
Organization Name:LUNA LAND DENTAL, CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JI HYUN
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:651-788-7045
Mailing Address - Street 1:393 DUNLAP ST N STE 308
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4223
Mailing Address - Country:US
Mailing Address - Phone:651-788-7045
Mailing Address - Fax:
Practice Address - Street 1:393 DUNLAP ST N STE 308
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4223
Practice Address - Country:US
Practice Address - Phone:651-788-7045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-06
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13905261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental