Provider Demographics
NPI:1538313408
Name:COLLEGE STREET DENTAL GROUP
Entity Type:Organization
Organization Name:COLLEGE STREET DENTAL GROUP
Other - Org Name:COLLEGE STREET DENTAL GROUP
Other - Org Type:Doing Business As
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:626-339-9085
Mailing Address - Street 1:153 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-2008
Mailing Address - Country:US
Mailing Address - Phone:626-339-9085
Mailing Address - Fax:
Practice Address - Street 1:153 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-2008
Practice Address - Country:US
Practice Address - Phone:626-339-9085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53724122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty