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General NPI Number Information
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NPI Number | 1194215442
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Entity Type | Organization
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Legal Business Name | D PARK PROFESSIONAL DENTAL CORP
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Dates
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Enumeration Date | 05/12/2018
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Last Update Date | 05/12/2018
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Provider Practice Location Address
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Address Line | 512 W 17TH ST STE B
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City | SANTA ANA
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State | CA
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Zip | 92706-3678
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Country | US
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Telephone | 714-210-0169
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Fax | 714-972-0162
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Provider Business Mailing Address
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Address Line | 512 W 17TH ST STE B
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City | SANTA ANA
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State | CA
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Zip | 92706-3678
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Country | US
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Telephone | 714-210-0169
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Fax | 714-972-0162
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Authorized Official
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Title or Position | OWNER
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Name | DAVID PARK
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Credential | DDS
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Telephone | 714-210-0169
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 53724
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License Number State | CA
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