Provider Demographics
NPI:1861739179
Name:PARK FAMILY & COSMETIC DENTISTRY
Entity type:Organization
Organization Name:PARK FAMILY & COSMETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MAI
Authorized Official - Middle Name:
Authorized Official - Last Name:HUYNH-LE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-263-1151
Mailing Address - Street 1:690 GOODLETTE FRANK RD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5613
Mailing Address - Country:US
Mailing Address - Phone:239-263-1151
Mailing Address - Fax:239-263-2725
Practice Address - Street 1:690 GOODLETTE FRANK RD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5613
Practice Address - Country:US
Practice Address - Phone:239-263-1151
Practice Address - Fax:239-263-2725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN163651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16-29117304OtherNPI TYPE 1