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General NPI Number Information
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NPI Number | 1871617027
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Entity Type | Individual
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Provider Name | CHAN M PARK MD
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Gender | Male
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Dates
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Enumeration Date | 03/16/2007
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Last Update Date | 07/25/2022
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Provider Practice Location Address
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Address Line | 3460 E LA PALMA AVE STE 202
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City | ANAHEIM
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State | CA
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Zip | 92806-2020
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Country | US
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Telephone | 833-574-2273
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Fax |
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Provider Business Mailing Address
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Address Line | 3460 E LA PALMA AVE STE 202
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City | ANAHEIM
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State | CA
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Zip | 92806-2020
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Country | US
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Telephone | 833-574-2273
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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 | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number | A109104
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License Number State | CA
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