MEDICARE: D PARK MPH DENTAL, 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
2	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922455914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	D PARK MPH DENTAL, INC

Provider Business Mailing Address
First Line	:	5802 PACIFIC BLVD
Second Line	:
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-2618
Country	:	US
Telephone Number	:	310-403-1117
Fax Number	:

Provider Business Practice Location Address
First Line	:	5802 PACIFIC BLVD
Second Line	:
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-2618
Country	:	US
Telephone Number	:	310-403-1117
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID S PARK
Credential	:	DDS
Telephone Number	:	310-403-1117

Provider Enumeration Date	:	05/19/2016
Last Update Date	:	12/04/2020

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