Provider Demographics
NPI:1700029964
Name:PARKS, DOUGLAS D (DDS)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:D
Last Name:PARKS
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 1:501 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-2247
Mailing Address - Country:US
Mailing Address - Phone:505-334-6116
Mailing Address - Fax:
Practice Address - Street 1:501 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-2247
Practice Address - Country:US
Practice Address - Phone:505-334-6116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1903122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1679507859OtherDENTAL OFFICE