Provider Demographics
NPI:1821611989
Name:PARK, SE HA (DMD)
Entity Type:Individual
Prefix:DR
First Name:SE HA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 MDG
Mailing Address - Street 2:UNIT 3215
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:09094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:86 MDG
Practice Address - Street 2:UNIT 3215
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09094
Practice Address - Country:US
Practice Address - Phone:314-479-2210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-24
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA04014169681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program