Provider Demographics
NPI:1992889687
Name:PARK, LAWRENCE EUGENE (DDS)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:EUGENE
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 1:1517 GREY BIRCH RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-9521
Mailing Address - Country:US
Mailing Address - Phone:260-625-3902
Mailing Address - Fax:
Practice Address - Street 1:10010 DUPONT CIRCLE CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1626
Practice Address - Country:US
Practice Address - Phone:260-490-4440
Practice Address - Fax:260-490-4448
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010099B1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice