Healthcare Provider Details

I. General information

NPI: 1386653095
Provider Name (Legal Business Name): CHRISTOPHER ALLEN PARKS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CUMBERLAND WAY SUITE A
SULLIVAN MO
63080-3321
US

IV. Provider business mailing address

400 CUMBERLAND WAY SUITE A
SULLIVAN MO
63080-3321
US

V. Phone/Fax

Practice location:
  • Phone: 573-468-7556
  • Fax: 573-468-7530
Mailing address:
  • Phone: 573-468-7556
  • Fax: 573-468-7530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number20030115559
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: