=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508010083
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID J PARK DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2008
-----------------------------------------------------
Last Update Date | 06/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2419 OCEAN AVE SUITE A
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-333-4232
-----------------------------------------------------
Fax | 415-333-4237
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2419 OCEAN AVE SUITE A
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94127-2606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-333-4232
-----------------------------------------------------
Fax | 415-333-4237
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | LL-187-08
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 58303
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------