Provider Demographics
NPI:1013963230
Name:PARK, DONG S (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONG
Middle Name:S
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 1:14100 PARK MEADOW DR STE 110
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-2292
Mailing Address - Country:US
Mailing Address - Phone:703-466-5115
Mailing Address - Fax:703-466-5502
Practice Address - Street 1:14100 PARK MEADOW DR STE 110
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-2292
Practice Address - Country:US
Practice Address - Phone:703-466-5115
Practice Address - Fax:703-466-5502
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014146361223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty