Basic Information
| Provider Information | |||||||||
| NPI: | 1477145449 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | XIONG | ||||||||
| FirstName: | PARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2590 49TH ST E | ||||||||
| Address2: | |||||||||
| City: | INVER GROVE HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550761158 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 636 BROADWAY ST NE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554132164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127461530 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2021 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 125J00000X | DT135 | MN | Y | Dental Providers | Dental Therapist |
No ID Information.