Provider Demographics
NPI:1194270231
Name:PARK, MICHAEL H (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:H
Last Name:PARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 VIA DEL MONTE
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-1612
Mailing Address - Country:US
Mailing Address - Phone:224-595-9132
Mailing Address - Fax:
Practice Address - Street 1:702 VIA DEL MONTE
Practice Address - Street 2:
Practice Address - City:PALOS VERDES ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-1612
Practice Address - Country:US
Practice Address - Phone:224-595-9132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI026722001223P0221X
CA1061201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry