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General NPI Number Information
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NPI Number | 1558284844
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Entity Type | Organization
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Legal Business Name | PAINESVILLE OH DENTIST LLC
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Dates
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Enumeration Date | 08/03/2026
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Last Update Date | 08/03/2026
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Provider Practice Location Address
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Address Line | 2183 MENTOR AVE
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City | PAINESVILLE
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State | OH
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Zip | 44077-1323
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Country | US
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Telephone | 651-444-9644
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Fax |
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Provider Business Mailing Address
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Address Line | 2183 MENTOR AVE
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City | PAINESVILLE
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State | OH
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Zip | 44077-1323
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO/PRESIDENT
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Name | DR. DAVID PARK
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Credential | DMD
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Telephone | 443-759-0910
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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