=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205596244
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTIE H. PARK, DDS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2021
-----------------------------------------------------
Last Update Date | 12/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 S GLENOAKS BLVD STE 12
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91502-1184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-846-2854
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2503 JANET LEE DR
-----------------------------------------------------
City | LA CRESCENTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91214-2237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/DENTIST
-----------------------------------------------------
Name | DR. CHRISTIE PARK
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 818-640-7781
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------