Provider Demographics
NPI:1083848568
Name:CLINTON PARK DENTAL CORPORATION
Entity Type:Organization
Organization Name:CLINTON PARK DENTAL CORPORATION
Other - Org Name:GATEWAY DENTAL GROUP AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:H
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-431-8112
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:2635 GATEWAY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-1753
Practice Address - Country:US
Practice Address - Phone:760-431-8112
Practice Address - Fax:760-929-8776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-12
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty