Sam Park, D.D.S.

Primary specialty

Pediatric DentistryTaxonomy code 1223P0221X

License

021002099 Issued in IL

Practice address

2959 S Wallace St
Children'S Dental World
Chicago, IL 60616-3034

Phone

(312) 326-5437

Fax

(312) 842-5338

NPI assigned

Jan 29, 2007

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Nov 12, 2018 through Nov 12, 2026

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Children'S Dental World, LLC

  • Pediatric Dentistry
  • Chicago, IL
  • NPI 1477883122
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170028800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1596672000000",
    "number": "1295871267",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2959 S WALLACE ST",
            "address_2": "CHILDREN'S DENTAL WORLD",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606163034",
            "telephone_number": "312-326-5437",
            "fax_number": "312-842-5338"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2959 S WALLACE ST",
            "address_2": "CHILDREN'S DENTAL WORLD",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606163034",
            "telephone_number": "312-326-5437",
            "fax_number": "312-842-5338"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "5826 Dempster St",
            "address_purpose": "LOCATION",
            "city": "Morton Grove",
            "state": "IL",
            "postal_code": "600533046",
            "country_code": "US",
            "telephone_number": "847-470-0665",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PARK",
        "first_name": "SAM",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-01-29",
        "last_updated": "2020-08-06",
        "certification_date": "2020-08-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "IL",
            "license": "021002099",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Min Seon Park
• Monica K Park, MD
• Peter Soohoon Park, MD
• Richard Park, LMFT
• Ryan Park
• Sang Park, D.D.S.
• Sarah Park, MD
• Seong Park
• Simon Park
• So-Yeon Park, D.D.S.

• Pediatric Dentistry in Chicago, IL
• Providers in Chicago, IL by specialty
• Pediatric Dentistry in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 6, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.