Provider Demographics
NPI:1740306414
Name:PARK, KWONIL (DDS)
Entity type:Individual
Prefix:DR
First Name:KWONIL
Middle Name:
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 1:1017 E TRINITY MILLS RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-1438
Mailing Address - Country:US
Mailing Address - Phone:972-446-7733
Mailing Address - Fax:972-446-0088
Practice Address - Street 1:1017 E TRINITY MILLS RD
Practice Address - Street 2:SUITE 102
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-1438
Practice Address - Country:US
Practice Address - Phone:972-446-7733
Practice Address - Fax:972-446-0088
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026108122300000X
TX250711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1005790Medicaid
TX207002108Medicaid