Provider Demographics
NPI:1578444162
Name:PARK, LENA (DMD)
Entity type:Individual
Prefix:
First Name:LENA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 AUBURN CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30011-5517
Mailing Address - Country:US
Mailing Address - Phone:480-327-8260
Mailing Address - Fax:
Practice Address - Street 1:1046 BRASELTON VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-2643
Practice Address - Country:US
Practice Address - Phone:706-954-5161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN30544122300000X
GADN123892122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist