Provider Demographics
NPI:1346659562
Name:DAVID S PARK DDS INC
Entity Type:Organization
Organization Name:DAVID S PARK DDS INC
Other - Org Name:EL CENTRO DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-403-1117
Mailing Address - Street 1:617 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-3218
Mailing Address - Country:US
Mailing Address - Phone:760-312-5888
Mailing Address - Fax:760-312-5918
Practice Address - Street 1:617 S 8TH ST
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-3218
Practice Address - Country:US
Practice Address - Phone:760-312-5888
Practice Address - Fax:760-312-5918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-13
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53724122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53724Medicaid