Provider Demographics
NPI:1659109163
Name:PARK, GEONWOONG (DDS)
Entity type:Individual
Prefix:
First Name:GEONWOONG
Middle Name:
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 1:661 HARDING RD APT 203E
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-9318
Mailing Address - Country:US
Mailing Address - Phone:323-428-6575
Mailing Address - Fax:
Practice Address - Street 1:5116 N BIG HOLLOW RD STE 101
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-3514
Practice Address - Country:US
Practice Address - Phone:315-454-6000
Practice Address - Fax:866-803-4943
Is Sole Proprietor?:No
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190353981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice