Provider Demographics
NPI:1477825677
Name:PARK, SIL (DMD)
Entity Type:Individual
Prefix:DR
First Name:SIL
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10833 LE CONTE AVE RM A0-156B
Mailing Address - Street 2:UC REGENTS MAXILLOFACIAL PROSTHODONTICS
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1668
Mailing Address - Country:US
Mailing Address - Phone:310-825-5889
Mailing Address - Fax:310-825-6345
Practice Address - Street 1:10833 LE CONTE AVE RM A0-156B
Practice Address - Street 2:UC REGENTS MAXILLOFACIAL PROSTHETICS
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1668
Practice Address - Country:US
Practice Address - Phone:310-825-5889
Practice Address - Fax:310-825-6345
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA594941223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics