Healthcare Provider Details

I. General information

NPI: 1306843669
Provider Name (Legal Business Name): RICHARD I. PARK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5415 SW WESTGATE DR SUITE 207
PORTLAND OR
97221-2409
US

IV. Provider business mailing address

5415 SW WESTGATE DR SUITE 207
PORTLAND OR
97221-2409
US

V. Phone/Fax

Practice location:
  • Phone: 503-292-9274
  • Fax: 503-292-2337
Mailing address:
  • Phone: 503-292-9274
  • Fax: 503-292-2337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number4262
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: