MEDICARE: D.S PARK DDS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	53724	CA

General Provider Information

NPI Number	:	1043641319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	D.S PARK DDS, INC

Provider Business Mailing Address
First Line	:	25285 MADISON AVE
Second Line	:	107
City	:	MURRIETA
State	:	CA
Zip	:	92562-8981
Country	:	US
Telephone Number	:	951-698-3585
Fax Number	:	951-698-3581

Provider Business Practice Location Address
First Line	:	25285 MADISON AVE
Second Line	:	107
City	:	MURRIETA
State	:	CA
Zip	:	92562-8981
Country	:	US
Telephone Number	:	951-698-3585
Fax Number	:	951-698-3581

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID PARK
Credential	:	DDS
Telephone Number	:	951-698-3585

Provider Enumeration Date	:	12/11/2013
Last Update Date	:	12/11/2013

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