=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336710011
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL PARK 4 PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2021
-----------------------------------------------------
Last Update Date | 07/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1801 S 5TH ST STE 112
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78503-2919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-682-1284
-----------------------------------------------------
Fax | 956-687-8373
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1801 S 5TH ST STE 112
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78503-2919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-682-1284
-----------------------------------------------------
Fax | 956-687-8373
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHAN MIN PARK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 956-682-1284
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------