Provider Demographics
NPI:1760025589
Name:DR D S PARK DENTAL INC
Entity Type:Organization
Organization Name:DR D S PARK DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-403-1117
Mailing Address - Street 1:1245 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WASCO
Mailing Address - State:CA
Mailing Address - Zip Code:93280-1820
Mailing Address - Country:US
Mailing Address - Phone:661-758-3021
Mailing Address - Fax:661-758-6780
Practice Address - Street 1:1245 7TH ST
Practice Address - Street 2:
Practice Address - City:WASCO
Practice Address - State:CA
Practice Address - Zip Code:93280-1820
Practice Address - Country:US
Practice Address - Phone:661-758-3021
Practice Address - Fax:661-758-6780
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR D S PARK DENTAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-24
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53724Medicaid