Provider Demographics
NPI:1669518676
Name:PARK, KYUNG WOOK (DDS)
Entity type:Individual
Prefix:DR
First Name:KYUNG
Middle Name:WOOK
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 1:9659 EATON WOODS PL
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-2338
Mailing Address - Country:US
Mailing Address - Phone:646-489-8909
Mailing Address - Fax:
Practice Address - Street 1:44031 PIPELINE PLZ
Practice Address - Street 2:SUITE 215
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5887
Practice Address - Country:US
Practice Address - Phone:646-489-8909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0512031223G0001X
VA04014118031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice