Provider Demographics
NPI:1851301998
Name:PARK, EDWIN M H (DDS)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:M H
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 1:95 N REINO ROAD
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-3708
Mailing Address - Country:US
Mailing Address - Phone:805-498-6640
Mailing Address - Fax:805-498-6640
Practice Address - Street 1:95 N REINO ROAD
Practice Address - Street 2:
Practice Address - City:NEWBURY PARK
Practice Address - State:CA
Practice Address - Zip Code:91320-3708
Practice Address - Country:US
Practice Address - Phone:805-498-6640
Practice Address - Fax:805-498-6640
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19375122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist