Provider Demographics
NPI:1881773679
Name:PARK, HYUN W (DDS)
Entity type:Individual
Prefix:
First Name:HYUN
Middle Name:W
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:256 N HAMMOND DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-2475
Mailing Address - Country:US
Mailing Address - Phone:770-207-0008
Mailing Address - Fax:770-207-0033
Practice Address - Street 1:256 N HAMMOND DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-2475
Practice Address - Country:US
Practice Address - Phone:770-207-0008
Practice Address - Fax:770-207-0033
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN128101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA858480563CMedicaid
GA858480563AMedicaid
GA858480563BMedicaid