MEDICARE: SANG HYUK PARK D.D.S.

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	47654	CA

General Provider Information

NPI Number	:	1669478871
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANG HYUK PARK D.D.S.

Provider Business Mailing Address
First Line	:	6383 PINE MEADOW CIR
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95219-2543
Country	:	US
Telephone Number	:	415-867-1603
Fax Number	:

Provider Business Practice Location Address
First Line	:	3040 PARK AVE
Second Line	:	STE H
City	:	MERCED
State	:	CA
Zip	:	95348-3405
Country	:	US
Telephone Number	:	209-722-7789
Fax Number	:	209-722-7811

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	04/24/2008

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