Dr. Park Dental Office 1, LLC

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

Legal business name

DR. PARK DENTAL OFFICE 1, LLC

Doing business as

Clear Lakes Dental

Practice address

1550 White Bear Ave N
Saint Paul, MN 55106-1602

Phone

(651) 788-7045

NPI assigned

Aug 8, 2022

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. David J Park, DMD

Title

Ceo/President/Owner

Phone

(651) 444-9644

Specialties & licenses 1

Addresses

Other names 1

• Clear Lakes Dental Doing business as

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Jacob William Des Jardins

  • General Practice Dentistry
  • Eagan, MN
  • NPI 1154017432
  NPD (past)
• Maxwell Ugochukwu Ogumgbuaja

  • General Practice Dentistry
  • Saint Paul, MN
  • NPI 1801726351
  NPD (past)
• Devon James Blob, DDS

  • General Practice Dentistry
  • Appleton, WI
  • NPI 1568148138
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1659916800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1659916800000",
    "number": "1508594664",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1550 WHITE BEAR AVE N",
            "city": "SAINT PAUL",
            "state": "MN",
            "postal_code": "551061602",
            "telephone_number": "651-788-7045"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1550 WHITE BEAR AVE N",
            "city": "SAINT PAUL",
            "state": "MN",
            "postal_code": "551061602",
            "telephone_number": "651-788-7045"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DR. PARK DENTAL OFFICE 1, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-08-08",
        "last_updated": "2022-08-08",
        "certification_date": "2022-08-08",
        "status": "A",
        "authorized_official_last_name": "PARK",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "CEO/PRESIDENT/OWNER",
        "authorized_official_telephone_number": "651-444-9644",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Clear Lakes Dental",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• General Practice Dentistry in Saint Paul, MN
• Providers in Saint Paul, MN by specialty
• General Practice Dentistry in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 8, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.