MEDICARE: KAYLA KOO DENTAL GROUP, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1134827959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAYLA KOO DENTAL GROUP, INC

Provider Business Mailing Address
First Line	:	4214 BEVERLY BLVD STE 209
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-4429
Country	:	US
Telephone Number	:	213-675-1824
Fax Number	:

Provider Business Practice Location Address
First Line	:	4214 BEVERLY BLVD STE 209
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-4429
Country	:	US
Telephone Number	:	213-675-1824
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. KAYLA KOO
Credential	:	DDS
Telephone Number	:	213-675-1824

Provider Enumeration Date	:	02/21/2023
Last Update Date	:	02/21/2023

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