Provider Demographics
NPI:1992475529
Name:TIMOTHY CHANG PARK DDS, INC
Entity type:Organization
Organization Name:TIMOTHY CHANG PARK DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:CHANGKEUN
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-940-8600
Mailing Address - Street 1:936 CRENSHAW BLVD # 100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-1957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14545 LEFFINGWELL RD # A&B
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90604-2898
Practice Address - Country:US
Practice Address - Phone:562-941-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental