Provider Demographics
NPI:1679748586
Name:PARK, DEAN MOON (DMD)
Entity type:Individual
Prefix:DR
First Name:DEAN
Middle Name:MOON
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 1:417 S LINCOLNWAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:NORTH AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60542-5109
Mailing Address - Country:US
Mailing Address - Phone:630-897-1300
Mailing Address - Fax:630-897-7172
Practice Address - Street 1:417 S LINCOLNWAY
Practice Address - Street 2:SUITE A
Practice Address - City:NORTH AURORA
Practice Address - State:IL
Practice Address - Zip Code:60542-5109
Practice Address - Country:US
Practice Address - Phone:630-897-1300
Practice Address - Fax:630-897-7172
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019020375122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist