Provider Demographics
NPI:1609450006
Name:D PARK MPH DDS DENTAL CORPORATION
Entity Type:Organization
Organization Name:D PARK MPH DDS DENTAL CORPORATION
Other - Org Name:SMILE DENTAL OF TRACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DDS/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-403-1117
Mailing Address - Street 1:2616 PAVILION PKWY STE 104
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95304-9408
Mailing Address - Country:US
Mailing Address - Phone:209-839-8333
Mailing Address - Fax:209-839-8338
Practice Address - Street 1:2616 PAVILION PKWY STE 104
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95304-9408
Practice Address - Country:US
Practice Address - Phone:209-839-8333
Practice Address - Fax:209-839-8338
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:D PARK MPH DDS DENTAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-11
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53724Medicaid