Provider Demographics
NPI:1104422245
Name:S PARK DDS INC
Entity type:Organization
Organization Name:S PARK DDS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-403-1117
Mailing Address - Street 1:6163 MACK RD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-4654
Mailing Address - Country:US
Mailing Address - Phone:888-585-3368
Mailing Address - Fax:661-471-2121
Practice Address - Street 1:6163 MACK RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-4654
Practice Address - Country:US
Practice Address - Phone:888-585-3368
Practice Address - Fax:661-471-2121
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:S PARK DDS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53724Medicaid