Provider Demographics
NPI:1700800497
Name:PARK, SOHEE KIM (DMD, MHS)
Entity Type:Individual
Prefix:DR
First Name:SOHEE
Middle Name:KIM
Last Name:PARK
Suffix:
Gender:F
Credentials:DMD, MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 CLEMSON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7925
Mailing Address - Country:US
Mailing Address - Phone:803-788-9715
Mailing Address - Fax:803-788-9705
Practice Address - Street 1:456 CLEMSON RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-7925
Practice Address - Country:US
Practice Address - Phone:803-788-9715
Practice Address - Fax:803-788-9705
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35921223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3592Medicaid