Healthcare Provider Details

I. General information

NPI: 1821907114
Provider Name (Legal Business Name): CAMINO VILLAGE DENTISTRY, PROF. CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

274 N EL CAMINO REAL STE C
ENCINITAS CA
92024-2859
US

IV. Provider business mailing address

PO BOX 660041
DALLAS TX
75266-0041
US

V. Phone/Fax

Practice location:
  • Phone: 760-330-5541
  • Fax: 760-452-8589
Mailing address:
  • Phone: 714-845-8890
  • Fax: 303-952-0892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CLINTON H PARK
Title or Position: OWNER
Credential: DDS
Phone: 760-330-5541