Provider Demographics
NPI:1831505098
Name:PARK, CHAN MIN (DDS)
Entity type:Individual
Prefix:
First Name:CHAN MIN
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 1:3303 LOS INDIOS PKWY
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-7584
Mailing Address - Country:US
Mailing Address - Phone:718-309-0944
Mailing Address - Fax:956-843-0179
Practice Address - Street 1:930 E EXPRESSWAY 83
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503
Practice Address - Country:US
Practice Address - Phone:956-843-0177
Practice Address - Fax:956-843-0179
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD41401223G0001X
TX320581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice