Provider Demographics
NPI:1568549798
Name:PARK, WAYNE M (DDS)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:M
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15231 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-4314
Mailing Address - Country:US
Mailing Address - Phone:310-327-4596
Mailing Address - Fax:310-327-1094
Practice Address - Street 1:15231 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-4314
Practice Address - Country:US
Practice Address - Phone:310-327-4596
Practice Address - Fax:310-327-1094
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA202471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice