Provider Demographics
NPI:1144452830
Name:PARK, ERIC (DMD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
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 1:97 EAGLE ROCK DR
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-1916
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4935 STEWART MILL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-6733
Practice Address - Country:US
Practice Address - Phone:770-627-3042
Practice Address - Fax:770-627-3243
Is Sole Proprietor?:No
Enumeration Date:2009-08-14
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0129461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics