Provider Demographics
NPI:1134527047
Name:PARK, MYUNG
Entity type:Individual
Prefix:
First Name:MYUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7770 SIGHTSEEING RD
Mailing Address - Street 2:DENCOM
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905-3764
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7770 SIGHTSEEING RD
Practice Address - Street 2:DENCOM
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-3764
Practice Address - Country:US
Practice Address - Phone:706-544-2118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.030083122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist