Provider Demographics
NPI:1275117491
Name:ETHAN PARK DMD INC
Entity Type:Organization
Organization Name:ETHAN PARK DMD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:SB
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:213-220-4856
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:626-544-5335
Mailing Address - Fax:626-544-5335
Practice Address - Street 1:5728 ROSEMEAD BLVD SUITE 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-12
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100873OtherDENTIST