Provider Demographics
NPI:1801213442
Name:PARK DDS MPH INC
Entity Type:Organization
Organization Name:PARK DDS MPH INC
Other - Org Name:GALT DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
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:209-744-0463
Mailing Address - Street 1:1067 C ST
Mailing Address - Street 2:125
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-1757
Mailing Address - Country:US
Mailing Address - Phone:209-744-0463
Mailing Address - Fax:209-744-8845
Practice Address - Street 1:1067 C ST
Practice Address - Street 2:125
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-1757
Practice Address - Country:US
Practice Address - Phone:209-744-0463
Practice Address - Fax:209-744-8845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53724122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53274Medicaid