Healthcare Provider Details

I. General information

NPI: 1497675235
Provider Name (Legal Business Name): JANICE PARK DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 REYNOLDS RANCH PKWY STE 100
LODI CA
95240-6890
US

IV. Provider business mailing address

1450 4TH ST APT 6
BERKELEY CA
94710-1328
US

V. Phone/Fax

Practice location:
  • Phone: 209-390-9379
  • Fax:
Mailing address:
  • Phone: 567-249-6430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS113364
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: