Provider Demographics
NPI:1508139890
Name:PARK, CHIN S (DMD)
Entity type:Individual
Prefix:DR
First Name:CHIN
Middle Name:S
Last Name:PARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 W PARK PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3566
Mailing Address - Country:US
Mailing Address - Phone:770-879-1200
Mailing Address - Fax:770-413-1821
Practice Address - Street 1:2415 W PARK PLACE BLVD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3566
Practice Address - Country:US
Practice Address - Phone:770-879-1200
Practice Address - Fax:770-413-1821
Is Sole Proprietor?:No
Enumeration Date:2012-02-16
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014213122300000X
GAFP29548991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist