Provider Demographics
NPI:1821721549
Name:PARK, SOO KYEONG (DENTIST(DMD))
Entity Type:Individual
Prefix:
First Name:SOO KYEONG
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DENTIST(DMD)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 TOWN CENTER AVE APT 221
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-5428
Mailing Address - Country:US
Mailing Address - Phone:347-944-7533
Mailing Address - Fax:
Practice Address - Street 1:9501 OLD ANNAPOLIS RD STE 200A
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-6336
Practice Address - Country:US
Practice Address - Phone:410-740-1484
Practice Address - Fax:410-740-1486
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD174861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice