Healthcare Provider Details

I. General information

NPI: 1275117491
Provider Name (Legal Business Name): ETHAN PARK DMD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2021
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5728 ROSEMEAD BLVD SUITE 220
TEMPLE CITY CA
91780-1814
US

IV. Provider business mailing address

5728 ROSEMEAD BLVD UNIT 220
TEMPLE CITY CA
91780-1814
US

V. Phone/Fax

Practice location:
  • Phone: 626-500-4340
  • Fax: 626-544-5335
Mailing address:
  • Phone: 626-544-5335
  • Fax: 626-544-5335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ETHAN SB PARK
Title or Position: OWNER DENTIST
Credential: DDS
Phone: 213-220-4856