Provider Demographics
NPI:1104317163
Name:REEBYE PARK & RICHMAN DDS PLC
Entity type:Organization
Organization Name:REEBYE PARK & RICHMAN DDS PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TECHNICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDRES
Authorized Official - Middle Name:F
Authorized Official - Last Name:HENAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-563-2897
Mailing Address - Street 1:1107 S FIFTH ST STE 250
Mailing Address - Street 2:
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302-9896
Mailing Address - Country:US
Mailing Address - Phone:919-563-2897
Mailing Address - Fax:919-563-2876
Practice Address - Street 1:200 E WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401
Practice Address - Country:US
Practice Address - Phone:336-272-4583
Practice Address - Fax:336-542-5164
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REEBYE PARK & RICHMAN DDS PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-25
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X
NC89761223P0106X
NC1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty