Provider Demographics
NPI:1306097993
Name:PARK, ENYOUNG (DDS)
Entity type:Individual
Prefix:
First Name:ENYOUNG
Middle Name:
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 1:230 W 55TH ST
Mailing Address - Street 2:APT 16E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-5220
Mailing Address - Country:US
Mailing Address - Phone:646-942-2245
Mailing Address - Fax:
Practice Address - Street 1:3711 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-1725
Practice Address - Country:US
Practice Address - Phone:718-361-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP644761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice