Provider Demographics
NPI:1487770715
Name:PARK, LISA WYSONG (DDS)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:WYSONG
Last Name:PARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:HWA
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3601 FREMONT AVE N
Mailing Address - Street 2:#316
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103
Mailing Address - Country:US
Mailing Address - Phone:206-675-0366
Mailing Address - Fax:206-675-0466
Practice Address - Street 1:3601 FREMONT AVE N
Practice Address - Street 2:316
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103
Practice Address - Country:US
Practice Address - Phone:206-675-0366
Practice Address - Fax:206-675-0466
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000068761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice