Basic Information
| Provider Information | |||||||||
| NPI: | 1629467659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | KI HONG | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2441 21ST ST | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988751 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2441 21ST ST | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988751 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2015 | ||||||||
| LastUpdateDate: | 07/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DN014638 | GA | Y | Dental Providers | Dentist |
No ID Information.