Provider Demographics
NPI:1063611747
Name:PARK, ROBERT D (DMD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:D
Last Name:PARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9727 GREENSIDE DR
Mailing Address - Street 2:
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-5030
Mailing Address - Country:US
Mailing Address - Phone:410-667-6404
Mailing Address - Fax:
Practice Address - Street 1:9727 GREENSIDE DR
Practice Address - Street 2:
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030-5030
Practice Address - Country:US
Practice Address - Phone:410-667-6404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014130361223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics