Provider Demographics
NPI:1548521248
Name:PARK, RAYMOND B (DDS)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:B
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 1:3105 ALDERWOOD MALL BLVD STE 117
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4745
Mailing Address - Country:US
Mailing Address - Phone:425-284-9886
Mailing Address - Fax:
Practice Address - Street 1:3105 ALDERWOOD MALL BLVD STE 117
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4745
Practice Address - Country:US
Practice Address - Phone:425-284-9886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE604671951223P0221X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry