Provider Demographics
NPI:1063942597
Name:D S PARK DDS MPH INC
Entity type:Organization
Organization Name:D S PARK DDS MPH INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:DE ARMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-325-4395
Mailing Address - Street 1:1120 OLIVEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-1210
Mailing Address - Country:US
Mailing Address - Phone:209-325-4395
Mailing Address - Fax:
Practice Address - Street 1:1120 OLIVEWOOD DR
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348
Practice Address - Country:US
Practice Address - Phone:209-263-1505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-18
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1942410501Medicaid