Provider Demographics
NPI:1982741112
Name:PARK, SO-YEON (DDS)
Entity Type:Individual
Prefix:DR
First Name:SO-YEON
Middle Name:
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 1:611 MILWAUKEE AVE
Mailing Address - Street 2:STE 185
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-7801
Mailing Address - Country:US
Mailing Address - Phone:847-998-0011
Mailing Address - Fax:
Practice Address - Street 1:2316 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-2228
Practice Address - Country:US
Practice Address - Phone:312-491-0601
Practice Address - Fax:312-491-0602
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026733122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9179986Medicaid