MEDICARE: CLEAN DENTAL OF DALLAS, P.C.

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	1223G0001X	General Practice Dentistry	23653	TX

General Provider Information

NPI Number	:	1912252750
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEAN DENTAL OF DALLAS, P.C.

Provider Business Mailing Address
First Line	:	4402 GUS THOMASSON RD
Second Line	:	SUITE A
City	:	MESQUITE
State	:	TX
Zip	:	75150-2232
Country	:	US
Telephone Number	:	214-765-6212
Fax Number	:

Provider Business Practice Location Address
First Line	:	4907 SPRING AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75210-1360
Country	:	US
Telephone Number	:	214-765-6212
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. SANG W PARK
Credential	:	DDS
Telephone Number	:	214-765-6213

Provider Enumeration Date	:	07/18/2012
Last Update Date	:	07/18/2012

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