Dental Board of California
Licensing details for: 16855
Name: CAMELLIA DENTISTRY, DENTAL PRACTICE OF ETHAN PARK, DMD, INC.
License Type: Fictitious Name Permit
Primary Status: Expired
Organization Classification: Corporation
License Relationships
FNP Owners
License/Registration Role: Fictitious Name Permit
Related Party Role: Owners
Name: PARK, ETHAN SANG BAE
Address Not Disclosed
FNP to DDS or OMS
License/Registration Role: Fictitious Name Permit
Related Party Role: Must hold an active Dental License, or Oral Maxillofacial Surgery Permit
Name: PARK, ETHAN SANG BAE
License/Registration Type: Dentist License
License Number: 100873 Primary Status: Current - Active
Address :
3860 2nd Ave
LA CRESCENTA CA 91214-2315
LOS ANGELES COUNTY
