Provider Demographics
NPI:1104961192
Name:PARK, MIOAK K (DDS)
Entity type:Individual
Prefix:DR
First Name:MIOAK
Middle Name:K
Last Name:PARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39260 PASEO PADRE PKWY
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1616
Mailing Address - Country:US
Mailing Address - Phone:510-791-2111
Mailing Address - Fax:510-791-0102
Practice Address - Street 1:39260 PASEO PADRE PKWY
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1616
Practice Address - Country:US
Practice Address - Phone:510-791-2111
Practice Address - Fax:510-791-0102
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA438371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice