MEDICARE: TIMOTHY C PARK DDS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1255935771
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIMOTHY C PARK DDS, INC

Provider Business Mailing Address
First Line	:	12124 GARFIELD AVE
Second Line	:
City	:	SOUTH GATE
State	:	CA
Zip	:	90280-8033
Country	:	US
Telephone Number	:	323-775-9070
Fax Number	:

Provider Business Practice Location Address
First Line	:	12122 GARFIELD AVE
Second Line	:
City	:	SOUTH GATE
State	:	CA
Zip	:	90280-8033
Country	:	US
Telephone Number	:	714-501-3433
Fax Number	:

Authorized Official
Title or Position	:	HEAD DOCTOR
Name	:	DR. TIMOTHY CHANGKEUN PARK
Credential	:	DDS
Telephone Number	:	714-501-3433

Provider Enumeration Date	:	11/25/2020
Last Update Date	:	01/14/2021

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