Provider Demographics
NPI:1790870996
Name:PARK, TAE H (DDS)
Entity Type:Individual
Prefix:
First Name:TAE
Middle Name:H
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:ANDY
Other - Middle Name:TAE H
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1875 E ALLUVIAL AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3856
Mailing Address - Country:US
Mailing Address - Phone:559-325-0700
Mailing Address - Fax:559-240-0907
Practice Address - Street 1:1875 E ALLUVIAL AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3856
Practice Address - Country:US
Practice Address - Phone:559-325-0700
Practice Address - Fax:559-240-0907
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA486591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice