MEDICARE: CHARLES C PARK D.D.S.

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	122300000X	Dentist	50087	CA

General Provider Information

NPI Number	:	1891865499
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES C PARK D.D.S.

Provider Business Mailing Address
First Line	:	1518 E LINCOLN AVE
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92865-1928
Country	:	US
Telephone Number	:	714-998-8998
Fax Number	:	714-998-0771

Provider Business Practice Location Address
First Line	:	1518 E LINCOLN AVE
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92865-1928
Country	:	US
Telephone Number	:	714-998-8998
Fax Number	:	714-998-0771

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

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	01/05/2017

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