Provider Demographics
NPI:1831527464
Name:PARK, SOOYEON (DMD)
Entity type:Individual
Prefix:
First Name:SOOYEON
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7501 TRAFALGAR CIR
Mailing Address - Street 2:APT 128
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076-5008
Mailing Address - Country:US
Mailing Address - Phone:608-469-9689
Mailing Address - Fax:
Practice Address - Street 1:5450 REISTERSTOWN RD
Practice Address - Street 2:SMILES R US
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-4434
Practice Address - Country:US
Practice Address - Phone:443-759-4844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD155671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice