Provider Demographics
NPI:1861686875
Name:PARK, AARON (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:AARON
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 S FIFTH ST STE 250
Mailing Address - Street 2:
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302-9896
Mailing Address - Country:US
Mailing Address - Phone:919-563-2873
Mailing Address - Fax:919-563-2876
Practice Address - Street 1:1107 S FIFTH ST STE 250
Practice Address - Street 2:
Practice Address - City:MEBANE
Practice Address - State:NC
Practice Address - Zip Code:27302-9896
Practice Address - Country:US
Practice Address - Phone:919-563-2873
Practice Address - Fax:919-563-2876
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-02
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052778122300000X
NC2017-02466204E00000X
NY269639208D00000X
NC92681223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5919946Medicaid
NY02888484Medicaid