Provider Demographics
NPI:1770826406
Name:PARK, DEREK (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:581 FOSTER CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-1695
Mailing Address - Country:US
Mailing Address - Phone:650-286-9999
Mailing Address - Fax:
Practice Address - Street 1:581 FOSTER CITY BLVD
Practice Address - Street 2:
Practice Address - City:FOSTER CITY
Practice Address - State:CA
Practice Address - Zip Code:94404-1695
Practice Address - Country:US
Practice Address - Phone:650-286-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA597481223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery