Provider Demographics
NPI:1508594664
Name:DR. PARK DENTAL OFFICE 1, LLC
Entity Type:Organization
Organization Name:DR. PARK DENTAL OFFICE 1, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:651-444-9644
Mailing Address - Street 1:1550 WHITE BEAR AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-1602
Mailing Address - Country:US
Mailing Address - Phone:651-788-7045
Mailing Address - Fax:
Practice Address - Street 1:1550 WHITE BEAR AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-1602
Practice Address - Country:US
Practice Address - Phone:651-788-7045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty