1609450006 NPI number — D PARK MPH DDS DENTAL CORPORATION

Table of content: (NPI 1609450006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609450006 NPI number — D PARK MPH DDS DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
D PARK MPH DDS DENTAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SMILE DENTAL OF TRACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609450006
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2616 PAVILION PKWY STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRACY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95304-9408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-839-8333
Provider Business Mailing Address Fax Number:
209-839-8338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2616 PAVILION PKWY STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRACY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95304-9408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-839-8333
Provider Business Practice Location Address Fax Number:
209-839-8338
Provider Enumeration Date:
05/11/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PARK
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
S
Authorized Official Title or Position:
DDS/CEO
Authorized Official Telephone Number:
310-403-1117

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 53724 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".