Provider Demographics
NPI:1710246798
Name:TRACY PARK D.D.S. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:TRACY PARK D.D.S. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:SUN
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-537-4427
Mailing Address - Street 1:2760 3RD STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-3220
Mailing Address - Country:US
Mailing Address - Phone:209-537-4427
Mailing Address - Fax:209-537-4437
Practice Address - Street 1:2760 3RD STREET
Practice Address - Street 2:SUITE A
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-3220
Practice Address - Country:US
Practice Address - Phone:209-537-4427
Practice Address - Fax:209-537-4437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-10
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X
CA41769261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty