Provider Demographics
NPI:1003999889
Name:PARK, ELIZABETH (DDS)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 ALLERMAN LN
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:89460
Mailing Address - Country:US
Mailing Address - Phone:775-782-8034
Mailing Address - Fax:775-882-3037
Practice Address - Street 1:501 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703
Practice Address - Country:US
Practice Address - Phone:775-882-1195
Practice Address - Fax:775-882-3037
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4703122300000X
CA52098122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist