Provider Demographics
NPI:1487883344
Name:PARK, CANDICE (DDS)
Entity type:Individual
Prefix:DR
First Name:CANDICE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:METUCHEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08840-2728
Mailing Address - Country:US
Mailing Address - Phone:323-509-8342
Mailing Address - Fax:
Practice Address - Street 1:244 MAIN ST
Practice Address - Street 2:
Practice Address - City:METUCHEN
Practice Address - State:NJ
Practice Address - Zip Code:08840-2728
Practice Address - Country:US
Practice Address - Phone:732-548-1218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI024129001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice