Provider Demographics
NPI:1538987680
Name:PAK, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:PAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4195 DENALI LN
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-5416
Mailing Address - Country:US
Mailing Address - Phone:626-221-5667
Mailing Address - Fax:
Practice Address - Street 1:10501 LAKEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-2709
Practice Address - Country:US
Practice Address - Phone:562-373-2722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110793122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist