Provider Demographics
NPI:1124660014
Name:CHAN M. PARK, D.D.S., M.D., PC AND BENJAMIN R. SHIMEL, D.D.S., PC A PA
Entity type:Organization
Organization Name:CHAN M. PARK, D.D.S., M.D., PC AND BENJAMIN R. SHIMEL, D.D.S., PC A PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:925-217-4884
Mailing Address - Street 1:111 DEERWOOD RD STE 130
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-2194
Mailing Address - Country:US
Mailing Address - Phone:925-217-4884
Mailing Address - Fax:925-217-4895
Practice Address - Street 1:111 DEERWOOD RD STE 130
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-2194
Practice Address - Country:US
Practice Address - Phone:925-217-4884
Practice Address - Fax:925-217-4895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty