Healthcare Provider Details

I. General information

NPI: 1275950818
Provider Name (Legal Business Name): D S PARK DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2014
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1037 E PALMDALE BLVD STE 203
PALMDALE CA
93550-4745
US

IV. Provider business mailing address

1037 E PALMDALE BLVD STE 203
PALMDALE CA
93550-4745
US

V. Phone/Fax

Practice location:
  • Phone: 661-272-9181
  • Fax: 661-272-8932
Mailing address:
  • Phone: 661-272-9181
  • Fax: 661-272-8932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number53724
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID S PARK
Title or Position: OWNER
Credential: DDS, MPH
Phone: 310-403-1117