Healthcare Provider Details

I. General information

NPI: 1205458767
Provider Name (Legal Business Name): GENE PARK DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18952 BROOKHURST ST
FOUNTAIN VALLEY CA
92708-7306
US

IV. Provider business mailing address

1641 VIA SEVILLA ST
CORONA CA
92881-0778
US

V. Phone/Fax

Practice location:
  • Phone: 714-716-1155
  • Fax:
Mailing address:
  • Phone: 559-970-2177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDDS108692
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: