Provider Demographics
NPI:1730433830
Name:PARK, KONY (DMD)
Entity type:Individual
Prefix:DR
First Name:KONY
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 1:30102 DIAMOND DOVE TRL
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-3724
Mailing Address - Country:US
Mailing Address - Phone:253-503-9655
Mailing Address - Fax:
Practice Address - Street 1:4913 MORELAND DR STE 103
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78633-5509
Practice Address - Country:US
Practice Address - Phone:512-275-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-29
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX366951223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics