Provider Demographics
NPI:1144779828
Name:PARK, ETHAN SB
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:SB
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5728 ROSEMEAD BLVD UNIT 220
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-1814
Mailing Address - Country:US
Mailing Address - Phone:626-500-4340
Mailing Address - Fax:626-544-5335
Practice Address - Street 1:5728 ROSEMEAD BLVD UNIT 220
Practice Address - Street 2:
Practice Address - City:TEMPLE CITY
Practice Address - State:CA
Practice Address - Zip Code:91780-1814
Practice Address - Country:US
Practice Address - Phone:626-500-4340
Practice Address - Fax:626-544-5335
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1008731223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100873OtherDENTIST