Active NPI
Aidan Park, DDS
- Dentist
- Kenosha, WI
National Provider Identifier
1639626450
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 1001421
- Practice address
- 6430 Green Bay Rd
Kenosha, WI 53142-2948 - Phone
- (888) 988-4066
- Fax
- (847) 496-4850
- NPI assigned
- Sep 9, 2016
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 1001421 | WI | Primary |
Addresses
Primary practice location
6430 Green Bay Rd
Kenosha, WI 53142-2948
Mailing address
2050 E Algonquin Rd
Ste 610
Schaumburg, IL 60173-4144
Phone (888) 988-4066
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in WI
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160914001287 | WI | Order and Referring Only - Dentist | 5294021440 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1001421 | WI | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1473379200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1473379200000",
"number": "1639626450",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2050 E ALGONQUIN RD",
"address_2": "STE 610",
"city": "SCHAUMBURG",
"state": "IL",
"postal_code": "601734144",
"telephone_number": "888-988-4066",
"fax_number": "847-496-4850"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "6430 GREEN BAY RD",
"city": "KENOSHA",
"state": "WI",
"postal_code": "531422948",
"telephone_number": "888-988-4066",
"fax_number": "847-496-4850"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PARK",
"first_name": "AIDAN",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2016-09-09",
"last_updated": "2016-09-09",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "WI",
"license": "1001421",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Kenosha, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 9, 2016; 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.