Provider Demographics
NPI:1407095599
Name:SALIDA DENTAL GROUP
Entity Type:Organization
Organization Name:SALIDA DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
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 1:5708 PIRRONE RD
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CA
Mailing Address - Zip Code:95368-9313
Mailing Address - Country:US
Mailing Address - Phone:209-543-3888
Mailing Address - Fax:
Practice Address - Street 1:5708 PIRRONE RD
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CA
Practice Address - Zip Code:95368-9313
Practice Address - Country:US
Practice Address - Phone:209-543-3888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53724122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty