Provider Demographics
NPI:1720386311
Name:PARK, ANTHONY T (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:T
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 1:3540 WILSHIRE BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2346
Mailing Address - Country:US
Mailing Address - Phone:231-384-3389
Mailing Address - Fax:213-384-3717
Practice Address - Street 1:3540 WILSHIRE BLVD STE 210
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2346
Practice Address - Country:US
Practice Address - Phone:231-384-3389
Practice Address - Fax:213-384-3717
Is Sole Proprietor?:No
Enumeration Date:2011-03-04
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30616122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist