Provider Demographics
NPI:1073615084
Name:PARK, TRACY S (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:S
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 1:2760 3RD STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307
Mailing Address - Country:US
Mailing Address - Phone:209-537-4427
Mailing Address - Fax:209-537-4437
Practice Address - Street 1:2760 3RD STREET
Practice Address - Street 2:SUITE A
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307
Practice Address - Country:US
Practice Address - Phone:209-537-4427
Practice Address - Fax:209-537-4437
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA417691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB4176901OtherDENTI-CAL