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512 W 17th St Ste B Santa Ana CA 92706-3678 | |
| (714) 210-0169 | |
| (714) 972-0162 |
| Full Name | |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 512 W 17th St Ste B, Santa Ana, California |
| Authorized Official Name and Position | David Park (OWNER) |
| Authorized Official Contact | 7142100169 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
512 W 17th St Ste B Santa Ana CA 92706-3678 Ph: (714) 210-0169 | 512 W 17th St Ste B Santa Ana CA 92706-3678 Ph: (714) 210-0169 |
| NPI Number | 1194215442 |
|---|---|
| Provider Enumeration Date | 05/12/2018 |
| Last Update Date | 05/12/2018 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1194215442 | NPI | - | NPPES |
| 53724 | Medicaid | CA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | 53724 (California) | Primary |
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