Healthcare Provider Details

I. General information

NPI: 1710340294
Provider Name (Legal Business Name): CLINTON H. PARK, D.D.S., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 04/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 SANTA FE DR
ENCINITAS CA
92024-5134
US

IV. Provider business mailing address

17000 RED HILL AVENUE
IRVINE CA
92614
US

V. Phone/Fax

Practice location:
  • Phone: 760-388-2161
  • Fax: 760-904-4035
Mailing address:
  • Phone: 714-845-8890
  • Fax: 949-474-1495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. CLINTON H PARK
Title or Position: OWNER
Credential: DDS
Phone: 760-388-2161