Healthcare Provider Details

I. General information

NPI: 1750489266
Provider Name (Legal Business Name): CLINTON H PARK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 ENCINITAS BLVD STE. 100
ENCINITAS CA
92024-2844
US

IV. Provider business mailing address

2860 MICHELLE 2ND FLOOR
IRVINE CA
92606-1009
US

V. Phone/Fax

Practice location:
  • Phone: 760-942-3900
  • Fax: 760-942-3909
Mailing address:
  • Phone: 714-508-3600
  • Fax: 714-368-2092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number48531
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: