Provider Demographics
NPI:1194215442
Name:D PARK PROFESSIONAL DENTAL CORP
Entity Type:Organization
Organization Name:D PARK PROFESSIONAL DENTAL CORP
Other - Org Name:CHILDREN & ADULT DENTISTRY- SANTA ANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-210-0169
Mailing Address - Street 1:512 W 17TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-3678
Mailing Address - Country:US
Mailing Address - Phone:714-210-0169
Mailing Address - Fax:714-972-0162
Practice Address - Street 1:512 W 17TH ST STE B
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-3678
Practice Address - Country:US
Practice Address - Phone:714-210-0169
Practice Address - Fax:714-972-0162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-12
Last Update Date:2018-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA537241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53724Medicaid