Healthcare Provider Details

I. General information

NPI: 1710898150
Provider Name (Legal Business Name): COLUMBUS PARK OH DENTIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 CLEVELAND AVE
COLUMBUS OH
43224-1577
US

IV. Provider business mailing address

125 LITTLE CANADA RD W STE 200
LITTLE CANADA MN
55117-1446
US

V. Phone/Fax

Practice location:
  • Phone: 651-444-9644
  • Fax:
Mailing address:
  • Phone: 651-444-9644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAVID PARK
Title or Position: CEO/PRESIDENT
Credential: DMD
Phone: 443-759-0910