Healthcare Provider Details

I. General information

NPI: 1215535182
Provider Name (Legal Business Name): PARK AND PARK DENTAL GROUP PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2020
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

473 E ALESSANDRO BLVD STE A
RIVERSIDE CA
92508-6021
US

IV. Provider business mailing address

473 E ALESSANDRO BLVD STE A
RIVERSIDE CA
92508-6021
US

V. Phone/Fax

Practice location:
  • Phone: 951-789-6886
  • Fax: 951-780-1998
Mailing address:
  • Phone: 951-789-6886
  • Fax: 951-780-1998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MYUNG KEE PARK
Title or Position: OWNER
Credential: DDS
Phone: 909-524-6119