Provider Demographics
NPI:1942354451
Name:PARK, PATRICK C (DDS)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:C
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 1:984 MONUMENT ST
Mailing Address - Street 2:208
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3857
Mailing Address - Country:US
Mailing Address - Phone:310-454-8911
Mailing Address - Fax:310-459-6951
Practice Address - Street 1:984 MONUMENT ST
Practice Address - Street 2:208
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3857
Practice Address - Country:US
Practice Address - Phone:310-454-8911
Practice Address - Fax:310-459-6951
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA445261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice