=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275347874
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARKS DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2025
-----------------------------------------------------
Last Update Date | 02/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2751 ROOSEVELT RD STE 203
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92106-6180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-450-8824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2751 ROOSEVELT RD STE 203
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92106-6180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-450-8824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRETT PARKS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 619-500-3592
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------