Provider Demographics
NPI:1891986378
Name:IAN PARK DDS PA
Entity Type:Organization
Organization Name:IAN PARK DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-474-8114
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:952-474-8114
Mailing Address - Fax:
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:952-474-8114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN99861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty