Provider Demographics
NPI:1508010083
Name:PARK, DAVID J (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
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 1:2419 OCEAN AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94127-2606
Mailing Address - Country:US
Mailing Address - Phone:415-333-4232
Mailing Address - Fax:415-333-4237
Practice Address - Street 1:2419 OCEAN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94127
Practice Address - Country:US
Practice Address - Phone:415-333-4232
Practice Address - Fax:415-333-4237
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLL-187-08122300000X
CA58303122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist