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2616 Pavilion Pkwy Ste 104 Tracy CA 95304-9408 | |
| (209) 839-8333 | |
| (209) 839-8338 |
| Full Name | |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 2616 Pavilion Pkwy Ste 104, Tracy, California |
| Authorized Official Name and Position | David S Park (DDS/CEO) |
| Authorized Official Contact | 3104031117 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
2616 Pavilion Pkwy Ste 104 Tracy CA 95304-9408 Ph: (209) 839-8333 | 2616 Pavilion Pkwy Ste 104 Tracy CA 95304-9408 Ph: (209) 839-8333 |
| NPI Number | 1609450006 |
|---|---|
| Provider Enumeration Date | 05/11/2021 |
| Last Update Date | 05/12/2021 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1609450006 | NPI | - | NPPES |
| 53724 | Medicaid | CA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | (* (Not Available)) | Primary |
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