Healthcare Provider Details

I. General information

NPI: 1558284844
Provider Name (Legal Business Name): PAINESVILLE OH DENTIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2183 MENTOR AVE
PAINESVILLE OH
44077-1323
US

IV. Provider business mailing address

2183 MENTOR AVE
PAINESVILLE OH
44077-1323
US

V. Phone/Fax

Practice location:
  • Phone: 651-444-9644
  • Fax:
Mailing address:
  • Phone:
  • 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: DR. DAVID PARK
Title or Position: CEO/PRESIDENT
Credential: DMD
Phone: 443-759-0910