Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 64009 | CA |
NPI | 1053713156 |
---|---|
Provider Name | Joseph Park |
First Address | Costa Mesa, CA 92627-2601 |
Second Address | Costa Mesa, CA 92627-2601 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/09/2014 |
Last Update Date | 26/07/2020 |