Healthcare Provider Details

I. General information

NPI: 1407040116
Provider Name (Legal Business Name): ANDREW C PARK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43000 MIDWAY AVE BLDG 595
SAN DIEGO CA
92140-5692
US

IV. Provider business mailing address

43000 MIDWAY AVE BLDG 595
SAN DIEGO CA
92140-5692
US

V. Phone/Fax

Practice location:
  • Phone: 619-524-4005
  • Fax:
Mailing address:
  • Phone: 619-524-4005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number59312
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: