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General NPI Number Information
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NPI Number | 1124289905
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Entity Type | Individual
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Provider Name | ETERN S PARK DDS, MD
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Gender | Male
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Dates
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Enumeration Date | 06/24/2008
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Last Update Date | 02/11/2025
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Provider Practice Location Address
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Address Line | 1717 UNIVERSITY DR S
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City | FARGO
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State | ND
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Zip | 58103-4939
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Country | US
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Telephone | 701-234-2000
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5074
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City | SIOUX FALLS
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State | SD
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Zip | 57117-5074
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Country | US
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Telephone | 605-328-6585
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 2503
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License Number State | ND
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | C1-0011804
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License Number State | DE
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Taxonomy #3
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | G3-0000458
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License Number State | DE
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Taxonomy #4
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number | 21037
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License Number State | ND
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Taxonomy #5
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number | 269333
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License Number State | NY
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Taxonomy #6
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 053210
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License Number State | NY
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