Active NPI
Kwonil Park, DDS
- General Practice Dentistry
- Carrollton, TX
National Provider Identifier
1740306414
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 25071
- Practice address
- 1017 E Trinity Mills Rd
Suite 102
Carrollton, TX 75006-1438 - Phone
- (972) 446-7733
- Fax
- (972) 446-0088
- NPI assigned
- Mar 22, 2007
- 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 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 019026108 | IL | |
| General Practice Dentistry | 1223G0001X | 25071 | TX | Primary |
Addresses
Primary practice location
1017 E Trinity Mills Rd
Suite 102
Carrollton, TX 75006-1438
Mailing address
1017 E Trinity Mills Rd
Suite 102
Carrollton, TX 75006-1438
Phone (972) 446-7733
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1005790 | Medicaid | IL | |
| 207002108 | Medicaid | TX |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019026108 | IL | MD | Dentist |
| 25071 | TX | MD | General Practice Dentistry |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| E Line Orthodontics | Past | Accepting new patients | |
| Total Dental Care PLLC | Dentist | Past | Accepting new patients |
Organizations & group practices 2
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.
-
- Dentist
- Carrollton, TX
- NPI 1437463494
-
- Orthodontics and Dentofacial Orthopedics Dentistry
- Carrollton, TX
- NPI 1700146966
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1174521600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1294704000000",
"number": "1740306414",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1017 E TRINITY MILLS RD",
"address_2": "SUITE 102",
"city": "CARROLLTON",
"state": "TX",
"postal_code": "750061438",
"telephone_number": "972-446-7733",
"fax_number": "972-446-0088"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1017 E TRINITY MILLS RD",
"address_2": "SUITE 102",
"city": "CARROLLTON",
"state": "TX",
"postal_code": "750061438",
"telephone_number": "972-446-7733",
"fax_number": "972-446-0088"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PARK",
"first_name": "KWONIL",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-03-22",
"last_updated": "2011-01-11",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "IL",
"license": "019026108",
"primary": false
},
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "TX",
"license": "25071",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1005790",
"state": "IL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "207002108",
"state": "TX"
}
],
"endpoints": [],
"other_names": []
}Other providers in Carrollton, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 11, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.