Healthcare Provider Details

I. General information

NPI: 1780192005
Provider Name (Legal Business Name): GH PARK DDS A DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 ROSECRANS AVE STE 104
FULLERTON CA
92833-1946
US

IV. Provider business mailing address

1031 ROSECRANS AVE STE 104
FULLERTON CA
92833-1946
US

V. Phone/Fax

Practice location:
  • Phone: 714-530-1948
  • Fax: 714-530-1186
Mailing address:
  • Phone: 714-530-1948
  • Fax: 310-530-1186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number49631
License Number StateCA

VIII. Authorized Official

Name: GENE PARK
Title or Position: PRESIDENT
Credential: DDS
Phone: 310-780-1296