Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 52767 | CA |
NPI | 1003945775 |
---|---|
Provider Name | Nanhee Park |
First Address | Paradise, CA 95969-5542 |
Second Address | Paradise, CA 95969-5542 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
52767 | (02) | CA |
BP7098660 | DEA # (01) | CA |