Provider Demographics
NPI:1053967794
Name:PARK, HEATHER HANA (DDS)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:HANA
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 1:43100 PALM ROYALE DR APT 426
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-7995
Mailing Address - Country:US
Mailing Address - Phone:909-438-7610
Mailing Address - Fax:
Practice Address - Street 1:78595 HIGHWAY 111 STE 300
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-2084
Practice Address - Country:US
Practice Address - Phone:760-771-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1042911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice