Healthcare Provider Details

I. General information

NPI: 1871773101
Provider Name (Legal Business Name): INGRID H PARK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2007
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2999 REGENT ST STE 408
BERKELEY CA
94705-2119
US

IV. Provider business mailing address

2999 REGENT ST STE 408
BERKELEY CA
94705-2119
US

V. Phone/Fax

Practice location:
  • Phone: 510-849-3613
  • Fax:
Mailing address:
  • Phone: 415-948-0380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number51369
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: