Provider Demographics
NPI:1033600952
Name:PARK, LINDA (DMD)
Entity type:Individual
Prefix:
First Name:LINDA
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 1:1443 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-4707
Mailing Address - Country:US
Mailing Address - Phone:617-232-8222
Mailing Address - Fax:
Practice Address - Street 1:1443 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-4707
Practice Address - Country:US
Practice Address - Phone:617-232-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1859046122300000X, 1223P0300X
NV72781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice