Provider Demographics
NPI:1174607832
Name:PARK, HAE DUK (DMD)
Entity type:Individual
Prefix:DR
First Name:HAE
Middle Name:DUK
Last Name:PARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:KEN
Other - Middle Name:HAE
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:8714 SUDLEY RD
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4405
Mailing Address - Country:US
Mailing Address - Phone:703-368-8166
Mailing Address - Fax:703-368-8624
Practice Address - Street 1:8714 SUDLEY RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4405
Practice Address - Country:US
Practice Address - Phone:703-368-8166
Practice Address - Fax:703-368-8624
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014105981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0401410598OtherVA DENTAL LIC#
PA1745319OtherUNITED CONCORDIA INS.ID
VA178830OtherANTHEM BCBS ID #
VA178830OtherANTHEM BCBS ID #