Healthcare Provider Details

I. General information

NPI: 1285119826
Provider Name (Legal Business Name): RAPHAEL S PARK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2018
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BDC EVANS
CHATAN OKINAWA
96379
JP

IV. Provider business mailing address

2115 AVENIDA SOLEDAD
FULLERTON CA
92833-1314
US

V. Phone/Fax

Practice location:
  • Phone: 714-681-0303
  • Fax:
Mailing address:
  • Phone: 714-681-0303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS103191
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: