Provider Demographics
NPI:1346079001
Name:PARK, KI DON (DDS)
Entity type:Individual
Prefix:
First Name:KI
Middle Name:DON
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 1:2060 EXPERIENCE AVE UNIT 537
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1397
Mailing Address - Country:US
Mailing Address - Phone:213-500-0135
Mailing Address - Fax:
Practice Address - Street 1:6395 S MCCARRAN BLVD STE B
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-6101
Practice Address - Country:US
Practice Address - Phone:775-823-9419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8090122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist