Provider Demographics
NPI:1215283403
Name:PARK, WOO KWON (DDS)
Entity type:Individual
Prefix:
First Name:WOO KWON
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E BLUFF ST
Mailing Address - Street 2:APT 7207
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-2300
Mailing Address - Country:US
Mailing Address - Phone:213-448-1888
Mailing Address - Fax:
Practice Address - Street 1:5701 LIBERTY GROVE RD
Practice Address - Street 2:SUITE 140
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75089-3623
Practice Address - Country:US
Practice Address - Phone:214-703-0703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-25
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61550122300000X
TX28444122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist