Provider Demographics
NPI:1831614213
Name:PARK, SAM S (DMD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:S
Last Name:PARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 CRESTRIDGE RD APT 210
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-3580
Mailing Address - Country:US
Mailing Address - Phone:310-344-8893
Mailing Address - Fax:
Practice Address - Street 1:1222 MAGNOLIA AVE STE 101
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-2075
Practice Address - Country:US
Practice Address - Phone:909-256-0456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS101611122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist