Active NPI
Douglas Lee Park, DDS
- Pediatric Dentistry
- Gresham, OR
National Provider Identifier
1366521122
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- License
- D6620
- Practice address
- 1201 SE 223Rd Ave
Suite 240
Gresham, OR 97030 - Phone
- (503) 666-9800
- Fax
- (503) 666-6787
- NPI assigned
- Nov 3, 2006
- Last updated
- Jul 8, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Dentistry | 1223P0221X | D6620 | OR | Primary |
Addresses
Primary practice location
1201 SE 223Rd Ave
Suite 240
Gresham, OR 97030
Mailing address
34116 SE Carpenter LN
Gresham, OR 97080
Phone (503) 663-5162
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| D6620 | OR | MD | Pediatric Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1162512000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1366521122",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "34116 SE CARPENTER LN",
"city": "GRESHAM",
"state": "OR",
"postal_code": "97080",
"telephone_number": "503-663-5162"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1201 SE 223RD AVE",
"address_2": "SUITE 240",
"city": "GRESHAM",
"state": "OR",
"postal_code": "97030",
"telephone_number": "503-666-9800",
"fax_number": "503-666-6787"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PARK",
"first_name": "DOUGLAS",
"middle_name": "LEE",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-11-03",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "OR",
"license": "D6620",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Gresham, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.