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General NPI Number Information
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NPI Number | 1558047712
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Entity Type | Individual
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Provider Name | ALICE PARK
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Gender | Female
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Dates
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Enumeration Date | 06/23/2023
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Last Update Date | 07/30/2025
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Provider Practice Location Address
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Address Line | 2310 CRAVEN ST
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City | SAN DIEGO
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State | CA
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Zip | 92136-4020
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Country | US
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Telephone | 619-556-8240
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Fax |
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Provider Business Mailing Address
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Address Line | 12198 FERNCREST PL
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City | SAN DIEGO
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State | CA
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Zip | 92128-4349
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Country | US
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Telephone | 858-442-5455
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Fax |
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 112159
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License Number State | CA
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