Healthcare Provider Details

I. General information

NPI: 1508594664
Provider Name (Legal Business Name): DR. PARK DENTAL OFFICE 1, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 WHITE BEAR AVE N
SAINT PAUL MN
55106-1602
US

IV. Provider business mailing address

1550 WHITE BEAR AVE N
SAINT PAUL MN
55106-1602
US

V. Phone/Fax

Practice location:
  • Phone: 651-788-7045
  • Fax:
Mailing address:
  • Phone: 651-788-7045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID J PARK
Title or Position: CEO/PRESIDENT/OWNER
Credential: DMD
Phone: 651-444-9644