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General NPI Number Information
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NPI Number | 1780192005
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Entity Type | Organization
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Legal Business Name | GH PARK DDS A DENTAL CORPORATION
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Dates
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Enumeration Date | 01/22/2018
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Last Update Date | 01/22/2018
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Provider Practice Location Address
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Address Line | 1031 ROSECRANS AVE STE 104
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City | FULLERTON
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State | CA
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Zip | 92833-1946
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Country | US
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Telephone | 714-530-1948
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Fax | 714-530-1186
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Provider Business Mailing Address
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Address Line | 1031 ROSECRANS AVE STE 104
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City | FULLERTON
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State | CA
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Zip | 92833-1946
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Country | US
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Telephone | 714-530-1948
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Fax | 310-530-1186
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Authorized Official
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Title or Position | PRESIDENT
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Name | GENE PARK
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Credential | DDS
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Telephone | 310-780-1296
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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 | 49631
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License Number State | CA
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