Provider Demographics
NPI:1609448646
Name:PARK, SAMUEL (DMD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
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 1:5306 TRACTOR LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-7239
Mailing Address - Country:US
Mailing Address - Phone:954-290-7165
Mailing Address - Fax:
Practice Address - Street 1:7050 AIR DEPOT BLVD BLDG 1094
Practice Address - Street 2:
Practice Address - City:TINKER AFB
Practice Address - State:OK
Practice Address - Zip Code:73145-8716
Practice Address - Country:US
Practice Address - Phone:954-290-7165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-10
Last Update Date:2024-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401417587122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist