Provider Demographics
NPI:1992145445
Name:PARK, HAN ICK (DDS)
Entity type:Individual
Prefix:
First Name:HAN ICK
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 OLD YORK RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3018
Mailing Address - Country:US
Mailing Address - Phone:215-456-7104
Mailing Address - Fax:
Practice Address - Street 1:334 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-4372
Practice Address - Country:US
Practice Address - Phone:410-685-0002
Practice Address - Fax:410-244-5001
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD16180122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist