Healthcare Provider Details

I. General information

NPI: 1043148091
Provider Name (Legal Business Name): POLARIS PARK OH DENTIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921-925 POLARIS PKWY
COLUMBUS OH
43240
US

IV. Provider business mailing address

921-925 POLARIS PKWY
COLUMBUS OH
43240
US

V. Phone/Fax

Practice location:
  • Phone: 763-260-5081
  • Fax:
Mailing address:
  • Phone:
  • 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 PARK
Title or Position: PRESIDENT/CEO
Credential: DMD
Phone: 443-759-0910