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General NPI Number Information
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NPI Number | 1447275375
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Entity Type | Individual
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Provider Name | TAEEEN PARK D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 07/13/2006
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Last Update Date | 07/16/2015
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Provider Practice Location Address
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Address Line | 190 SOUTH OAK AVE. BLDG.3 STE 6
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City | OAKDALE
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State | CA
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Zip | 95361-3528
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Country | US
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Telephone | 209-847-2800
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Fax | 209-847-2929
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Provider Business Mailing Address
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Address Line | 190 S. OAK AVE BLDG 3 STE 6
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City | OAKDALE
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State | CA
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Zip | 95361-3528
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Country | US
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Telephone | 209-847-2800
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Fax | 209-847-2929
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 56889
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License Number State | CA
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