Provider Demographics
NPI:1942410501
Name:PARK, DAVID S (DDS, MPH)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:S
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 VIA DEL CIELO
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-2511
Mailing Address - Country:US
Mailing Address - Phone:310-403-1117
Mailing Address - Fax:310-403-1117
Practice Address - Street 1:10390 COLOMA RD STE A
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-2152
Practice Address - Country:US
Practice Address - Phone:916-368-0440
Practice Address - Fax:916-368-0440
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA537241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice