Healthcare Provider Details

I. General information

NPI: 1962894170
Provider Name (Legal Business Name): PARK DENTAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2015
Last Update Date: 02/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 N PALM ST
TURLOCK CA
95380-4028
US

IV. Provider business mailing address

241 N PALM ST
TURLOCK CA
95380-4028
US

V. Phone/Fax

Practice location:
  • Phone: 209-667-2254
  • Fax: 209-667-2274
Mailing address:
  • Phone: 209-667-2254
  • Fax: 209-667-2274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number53191
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number57684
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number53724
License Number StateCA

VIII. Authorized Official

Name: DAVID PARK
Title or Position: DIRECTOR
Credential: DDS
Phone: 209-667-2254