Healthcare Provider Details

I. General information

NPI: 1891143780
Provider Name (Legal Business Name): DAVID SANGHO PARK DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12732 SAN PABLO AVE
RICHMOND CA
94805-1303
US

IV. Provider business mailing address

12732 SAN PABLO AVE
RICHMOND CA
94805-1303
US

V. Phone/Fax

Practice location:
  • Phone: 510-233-3100
  • Fax: 510-233-3434
Mailing address:
  • Phone: 510-233-3100
  • Fax: 510-233-3434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateCA

VIII. Authorized Official

Name: BRANDI DE ARMON
Title or Position: REGIONAL MANAGER
Credential:
Phone: 209-263-1505