Provider Demographics
NPI:1194194506
Name:PARK, KWANG MIN
Entity type:Individual
Prefix:DR
First Name:KWANG MIN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2660 N BUFFALO DR UNIT 1322
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-4829
Mailing Address - Country:US
Mailing Address - Phone:781-325-5634
Mailing Address - Fax:
Practice Address - Street 1:7171 W CRAIG RD STE 102
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-6018
Practice Address - Country:US
Practice Address - Phone:702-655-0331
Practice Address - Fax:702-655-0377
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856730122300000X
NV74701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist