Provider Demographics
NPI:1861494791
Name:PARK, IAN ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:ANTHONY
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17705 HUTCHINS DR
Mailing Address - Street 2:SUITE 209
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-4145
Mailing Address - Country:US
Mailing Address - Phone:925-474-8114
Mailing Address - Fax:952-474-5195
Practice Address - Street 1:17705 HUTCHINS DR
Practice Address - Street 2:SUITE 209
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-4145
Practice Address - Country:US
Practice Address - Phone:925-474-8114
Practice Address - Fax:952-474-5195
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN99861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN615022500Medicare ID - Type Unspecified