Provider Demographics
NPI:1063889558
Name:TAE EEN PARK,D.D.S.,INC
Entity type:Organization
Organization Name:TAE EEN PARK,D.D.S.,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TAE EEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-847-2800
Mailing Address - Street 1:190 S. OAK AVE BLDG 3 STE 6
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361
Mailing Address - Country:US
Mailing Address - Phone:209-847-2800
Mailing Address - Fax:209-847-2929
Practice Address - Street 1:190 S OAK AVE STE 6
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-3528
Practice Address - Country:US
Practice Address - Phone:209-847-2800
Practice Address - Fax:209-847-2929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56889261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========Medicaid