Healthcare Provider Details

I. General information

NPI: 1639090020
Provider Name (Legal Business Name): HELEN PARK
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15201 S WESTERN AVE
GARDENA CA
90249-4314
US

IV. Provider business mailing address

15201 S WESTERN AVE
GARDENA CA
90249-4314
US

V. Phone/Fax

Practice location:
  • Phone: 310-400-7705
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113278
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: