Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 0401413036 | VA |
NPI | 1063611747 |
---|---|
Provider Name | Dr. Robert D Park |
First Address | Cockeysville, MD 21030-5030 |
Second Address | Cockeysville, MD 21030-5030 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/07/2007 |
Last Update Date | 21/09/2015 |