Provider Demographics
NPI:1306491261
Name:PARK, PAUL J (DMD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:J
Last Name:PARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 CLARKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GREGG-ADAMS
Mailing Address - State:VA
Mailing Address - Zip Code:23801
Mailing Address - Country:US
Mailing Address - Phone:804-734-9607
Mailing Address - Fax:
Practice Address - Street 1:2601 CLARKE AVE
Practice Address - Street 2:
Practice Address - City:FORT GREGG-ADAMS
Practice Address - State:VA
Practice Address - Zip Code:23801
Practice Address - Country:US
Practice Address - Phone:804-734-9747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-07
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401419061122300000X
VA04380005061223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist