Provider Demographics
NPI:1780762807
Name:PARK, GAIL ENGASSER (DDS)
Entity type:Individual
Prefix:DR
First Name:GAIL
Middle Name:ENGASSER
Last Name:PARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15011 LINNER RDG
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-2244
Mailing Address - Country:US
Mailing Address - Phone:952-473-0446
Mailing Address - Fax:
Practice Address - Street 1:6600 EXCELSIOR BLVD
Practice Address - Street 2:SUITE 191
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4744
Practice Address - Country:US
Practice Address - Phone:952-931-9961
Practice Address - Fax:952-931-3944
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9375122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU74918Medicare UPIN