Healthcare Provider Details

I. General information

NPI: 1710246798
Provider Name (Legal Business Name): TRACY PARK D.D.S. A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2760 3RD STREET SUITE A
CERES CA
95307-3220
US

IV. Provider business mailing address

2760 3RD STREET SUITE A
CERES CA
95307-3220
US

V. Phone/Fax

Practice location:
  • Phone: 209-537-4427
  • Fax: 209-537-4437
Mailing address:
  • Phone: 209-537-4427
  • Fax: 209-537-4437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number41769
License Number StateCA

VIII. Authorized Official

Name: MRS. TRACY SUN PARK
Title or Position: DENTIST/OWNER
Credential:
Phone: 209-537-4427