Healthcare Provider Details

I. General information

NPI: 1134734353
Provider Name (Legal Business Name): MARK PARK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 12/14/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDDAC-BAVARIA CMR 411
APO AE
09112
US

IV. Provider business mailing address

MEDDAC-BAVARIA CMR 411
APO AE
09112
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-2800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS105513
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: