MEDICARE: DR. RICHARD I. PARK DMD

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	1223P0221X	Pediatric Dentistry	4262	OR

General Provider Information

NPI Number	:	1306843669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD I. PARK DMD

Provider Business Mailing Address
First Line	:	5415 SW WESTGATE DR
Second Line	:	SUITE 207
City	:	PORTLAND
State	:	OR
Zip	:	97221-2409
Country	:	US
Telephone Number	:	503-292-9274
Fax Number	:	503-292-2337

Provider Business Practice Location Address
First Line	:	5415 SW WESTGATE DR
Second Line	:	SUITE 207
City	:	PORTLAND
State	:	OR
Zip	:	97221-2409
Country	:	US
Telephone Number	:	503-292-9274
Fax Number	:	503-292-2337

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	07/08/2007

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