Provider Demographics
NPI:1891482337
Name:PARK, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25604 VIA VENTANA
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91381-0642
Mailing Address - Country:US
Mailing Address - Phone:661-476-2009
Mailing Address - Fax:
Practice Address - Street 1:25604 VIA VENTANA
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91381-0642
Practice Address - Country:US
Practice Address - Phone:661-476-2009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109001122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist