Basic Information
Provider Information | |||||||||
NPI: | 1134405731 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARK | ||||||||
FirstName: | KUNHA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PARK | ||||||||
OtherFirstName: | KEVIN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DMD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2605 | ||||||||
Address2: |   | ||||||||
City: | YAKIMA | ||||||||
State: | WA | ||||||||
PostalCode: | 989072605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5094544143 | ||||||||
FaxNumber: | 5094543651 | ||||||||
Practice Location | |||||||||
Address1: | 12 S 8TH ST | ||||||||
Address2: |   | ||||||||
City: | YAKIMA | ||||||||
State: | WA | ||||||||
PostalCode: | 989013020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5094544143 | ||||||||
FaxNumber: | 5094543651 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/26/2011 | ||||||||
LastUpdateDate: | 10/26/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DE60232679 | WA | Y |   | Dental Providers | Dentist |   |
No ID Information.