Provider Demographics
NPI:1124572284
Name:D PARK MPH DDS DENTAL CORPORATION
Entity Type:Organization
Organization Name:D PARK MPH DDS DENTAL CORPORATION
Other - Org Name:PACIFIC DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO, CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SANGHO
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MPH
Authorized Official - Phone:310-403-1117
Mailing Address - Street 1:7743 WEST LN STE C5
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-3381
Mailing Address - Country:US
Mailing Address - Phone:209-474-1101
Mailing Address - Fax:209-474-9734
Practice Address - Street 1:7743 WEST LN STE C5
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-3381
Practice Address - Country:US
Practice Address - Phone:209-474-1101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:D PARK MPH DDS DENTAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-06
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53724Medicaid