Healthcare Provider Details

I. General information

NPI: 1891865499
Provider Name (Legal Business Name): CHARLES C PARK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 S MAIN ST
SANTA ANA CA
92707-1836
US

IV. Provider business mailing address

1702 S MAIN ST
SANTA ANA CA
92707-1836
US

V. Phone/Fax

Practice location:
  • Phone: 714-972-2828
  • Fax: 714-972-2829
Mailing address:
  • Phone: 714-972-2828
  • Fax: 714-972-2829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number50087
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: