Provider Demographics
NPI:1477196244
Name:DR D S PARK DENTAL INC
Entity Type:Organization
Organization Name:DR D S PARK DENTAL INC
Other - Org Name:SMILE DENTAL OF DELANO
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 1:1406 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:CA
Mailing Address - Zip Code:93215-2222
Mailing Address - Country:US
Mailing Address - Phone:661-725-9430
Mailing Address - Fax:661-725-7221
Practice Address - Street 1:1406 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-2222
Practice Address - Country:US
Practice Address - Phone:661-725-9430
Practice Address - Fax:661-725-7221
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR D S PARK DENTAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-23
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53724Medicaid