Provider Demographics
NPI:1386460483
Name:DJ PARK DMD INC
Entity type:Organization
Organization Name:DJ PARK DMD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-259-7763
Mailing Address - Street 1:2419 OCEAN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94127-2624
Mailing Address - Country:US
Mailing Address - Phone:415-333-4232
Mailing Address - Fax:
Practice Address - Street 1:2419 OCEAN AVE STE A
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94127-2624
Practice Address - Country:US
Practice Address - Phone:415-333-4232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-23
Last Update Date:2024-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty