Provider Demographics
NPI:1659853364
Name:DR. D. PARK DDS, INC.
Entity Type:Organization
Organization Name:DR. D. PARK DDS, INC.
Other - Org Name:SMILE DENTAL OF VISTA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-431-1117
Mailing Address - Street 1:1279 E VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-4039
Mailing Address - Country:US
Mailing Address - Phone:760-208-2518
Mailing Address - Fax:760-340-3464
Practice Address - Street 1:1279 E VISTA WAY
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-4039
Practice Address - Country:US
Practice Address - Phone:760-208-2518
Practice Address - Fax:760-340-3464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53724122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53724Medicaid