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General NPI Number Information
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NPI Number | 1124660014
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Entity Type | Organization
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Legal Business Name | CHAN M. PARK, D.D.S., M.D., PC AND BENJAMIN R. SHIMEL, D.D.S., PC A PA
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Dates
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Enumeration Date | 10/11/2019
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Last Update Date | 10/11/2019
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Provider Practice Location Address
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Address Line | 111 DEERWOOD RD STE 130
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City | SAN RAMON
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State | CA
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Zip | 94583-2194
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Country | US
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Telephone | 925-217-4884
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Fax | 925-217-4895
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Provider Business Mailing Address
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Address Line | 111 DEERWOOD RD STE 130
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City | SAN RAMON
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State | CA
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Zip | 94583-2194
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Country | US
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Telephone | 925-217-4884
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Fax | 925-217-4895
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Authorized Official
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Title or Position | PARTNER
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Name | CHAN M PARK
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Credential | MD, DDS
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Telephone | 925-217-4884
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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 |
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License Number State |
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