Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 56339 | CA |
NPI | 1003094426 |
---|---|
Provider Name | Dr. Kyungsin Park |
First Address | Riverside, CA 92508-5083 |
Second Address | Riverside, CA 92508-5083 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/02/2008 |
Last Update Date | 26/12/2011 |