Provider Demographics
NPI:1457455966
Name:PARK DENTAL CENTER PROFESSIONAL LLC
Entity Type:Organization
Organization Name:PARK DENTAL CENTER PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAE
Authorized Official - Middle Name:EEN
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-368-3636
Mailing Address - Street 1:2900 S PEORIA ST STE A
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-3182
Mailing Address - Country:US
Mailing Address - Phone:303-368-3636
Mailing Address - Fax:303-368-3631
Practice Address - Street 1:2900 S PEORIA ST STE A
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-3182
Practice Address - Country:US
Practice Address - Phone:303-368-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO89621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02270781Medicaid