Basic Information
| Provider Information | |||||||||
| NPI: | 1306097993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | ENYOUNG | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 230 W 55TH ST | ||||||||
| Address2: | APT 16E | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100195220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6469422245 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3711 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | LONG ISLAND CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111011725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183615155 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2008 | ||||||||
| LastUpdateDate: | 09/21/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | P64476 | NY | Y | Dental Providers | Dentist | General Practice |
No ID Information.