MEDICARE: PARK 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	1223E0200X	Endodontics	53191	CA
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	57684	CA
3	122300000X	Dentist	53724	CA

General Provider Information

NPI Number	:	1962894170
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK DENTAL, INC.

Provider Business Mailing Address
First Line	:	241 N PALM ST
Second Line	:
City	:	TURLOCK
State	:	CA
Zip	:	95380-4028
Country	:	US
Telephone Number	:	209-667-2254
Fax Number	:	209-667-2274

Provider Business Practice Location Address
First Line	:	241 N PALM ST
Second Line	:
City	:	TURLOCK
State	:	CA
Zip	:	95380-4028
Country	:	US
Telephone Number	:	209-667-2254
Fax Number	:	209-667-2274

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DAVID PARK
Credential	:	DDS
Telephone Number	:	209-667-2254

Provider Enumeration Date	:	02/25/2015
Last Update Date	:	02/26/2015

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Directions to “PARK DENTAL, INC. ” Practice Location

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