Healthcare Provider Details

I. General information

NPI: 1457985574
Provider Name (Legal Business Name): BRETT PARKS D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7011 LINDA VISTA RD
SAN DIEGO CA
92111-6307
US

IV. Provider business mailing address

7011 LINDA VISTA RD
SAN DIEGO CA
92111-6307
US

V. Phone/Fax

Practice location:
  • Phone: 775-450-8824
  • Fax:
Mailing address:
  • Phone: 775-450-8824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number107435
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: