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General NPI Number Information
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NPI Number | 1912252750
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Entity Type | Organization
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Legal Business Name | CLEAN DENTAL OF DALLAS, P.C.
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Dates
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Enumeration Date | 07/18/2012
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Last Update Date | 07/18/2012
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Provider Practice Location Address
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Address Line | 4907 SPRING AVE
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City | DALLAS
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State | TX
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Zip | 75210-1360
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Country | US
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Telephone | 214-765-6212
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Fax |
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Provider Business Mailing Address
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Address Line | 4402 GUS THOMASSON RD SUITE A
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City | MESQUITE
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State | TX
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Zip | 75150-2232
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Country | US
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Telephone | 214-765-6212
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. SANG W PARK
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Credential | DDS
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Telephone | 214-765-6213
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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 | 23653
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License Number State | TX
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