Provider Demographics
NPI:1598713380
Name:PARK, DANIEL I (DMD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:I
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 1:2200 DEFENSE HWY STE 208
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2927
Mailing Address - Country:US
Mailing Address - Phone:410-721-0790
Mailing Address - Fax:443-292-4214
Practice Address - Street 1:2200 DEFENSE HWY STE 208
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2927
Practice Address - Country:US
Practice Address - Phone:410-721-0790
Practice Address - Fax:443-292-4214
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD138281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice